ABCD State Resources

North Carolina developed a best practice comprehensive community model that builds on its "physician driven" enhanced primary care case management program, Community Care of North Carolina, and is characterized by introduction and integration of a standardized validated screening tool and collaboration with local and state agency staff and families. Since the ABCD project officially ended, the stakeholder group has continued to meet, policy improvements have been adopted at the state level, and additional practices have replicated the ABCD model.

The Connecticut ABCD Screening Academy Project improved the quality of preventive pediatric care by enhancing expectations of providers participating in their EPSDT program. Connecticut developed policies to help pediatric practices implement AAP-recommended screenings and to connect children identified through screening to needed resources. Connecticut also developed a plan for a statewide system of structured screening and to ensure that policies are implemented across all practice settings.

Specifically, the ABCD Screening Academy in Connecticut improved developmental screening by:

• Revising policies to allow for the 96110 to be billed on the same day as a well child visit or an evaluation and management (E & M) visit, revising reimbursement rates, and implementing a Pay for Performance (P4P) program.
• Sustaining structured developmental screening by partnering with the Child Health and Development Institute of Connecticut (CHDI) and the Help Me Grow Initiative to revise the Educating Practice in their Communities (EPIC) model to reflect the changes in Medicaid policy and working directly with physician's offices to spread the word about these changes.

The New Jersey ABCD Screening Academy project developed and built on public and private partnerships to promote screening using the medical home model, and focused on improving linkages between primary care providers and existing referral resources.

Specifically, the ABCD Screening Academy activities in New Jersey included:

• Negotiating a contract between New Jersey Health and Senior Services and the Pediatric Council on Research and Education (PCORE) for a $125,000 grant to expand and strengthen medical homes in New Jersey and incorporate structured developmental screening into primary care. 
• Providing the Ages and Stages Questionnaire (ASQ), staff time, resources and technical assistance to demonstration sites. 
• Hosting ASQ trainings and informational workshops statewide, including building on partnerships with the Medicaid Health Maintenance Organizations (HMOs) who incorporated the topic of developmental screening into their EPSDT trainings. 
• Facilitating collaboration between the demonstration site and Early Intervention (EI) staff to promote improved linkages. 
• Sustaining and spreading improvement activities through several grant applications, one to replicate ABCD efforts with other primary care providers to implement structured screening and surveillance techniques as part of routine well health supervision within the context of a medical home and another for the early identification (screening) and referral of young children with autism including a 2 year subcontract for $91,000 to PCORE.

The Maryland ABCD Screening Academy Project improved state policy by identifying and implementing policy improvements needed to support effective screening. Maryland supported the adoption of screening in two demonstration sites and is working to initiate statewide spread of structured developmental screening.  Specifically, the ABCD Screening Academy activities in Maryland included:  

• Increasing Medicaid reimbursement for CPT 96111; approving reimbursement for up to 2 units of CPT 96110 on the same date of service when a objective, validated autism or social/emotional screening tool is administered in addition to a general developmental screening tool; and updating their EPSDT/Healthy Kids provider manual and periodicity schedule to reflect the recommendations of the 2006 AAP policy statement on developmental screening and surveillance and the revised reimbursement policies.
• Developing and approving a standard, universal referral and fax back form for use statewide that was piloted within the ABCD demonstration sites to promote linkages between primary care and other child and family service providers.  
• Sustaining improvement activities by disseminating the AAP policy statement and information about developmental screening using standardized tools to pediatricians and family practitioners during site visits throughout the state as well as a list of approved and recommended screening tools for use by EPSDT providers and the criteria for making future additions to this list. 
• Spreading structured screening by acquiring a 3-year grant from the Maternal and Child Health Bureau that will focus on improving the quality of developmental services and promote linkages between primary care providers and other child and family service providers for young children and their families by replicating ABCD Screening Academy demonstration site activities. 

The Virginia ABCD Screening Academy Project focused on assuring that young children receive necessary developmental screenings. Building on existing resources and partnerships with, among others, the state AAP Chapter, Department of Education, and Part C Early Intervention program, Virginia conducted pilot programs to promote statewide spread of the use of structured developmental screening and to promote linkages between primary care and referral resources.

Specifically, the ABCD Screening Academy activities in Virginia included:

• Developing a uniform referral/consent form to facilitate communication between the Infant & Toddler Connection early intervention program and providers; developing a list of recommended objective, validated developmental screening tools for use in EPSDT; recommending Medicaid reimbursement for the use of a maternal depression screening tool; and revising language regarding developmental screening for the SFY 2009 Medicaid managed care contracts.
• Developing and distributing a laminated referral guide for the Infant & Toddler Connection of Virginia early intervention program that expressly encourages screening using an objective, validated screening tool.
• Providing the Ages and Stages Questionnaire (ASQ) tool and training to all public health districts and developing a structured screening implementation tool kit for pilot sites and others practices wishing to adopt structured screening. 
• Sustaining and spreading these improvements by promoting ABCD Stakeholders Group recommendations and guidelines for screening tool selection, adoption, and resulting referral processes statewide which will assure that programs serving families with young children are receiving uniform information about the implementation of structured developmental screening tools and guidelines.

The Ohio ABCD Screening Academy Project tested the adoption of structured developmental and social-emotional screening in several pilot practice sites to improve the quality of child development services.  The ABCD team integrated and supported existing initiatives and resources by promoting linkages between primary care and the Help Me Grow (Part C/Early Intervention) and Title V programs. Ohio also supported the state AAP Chapter’s statewide spread efforts.  Specifically, the ABCD Screening Academy activities in Ohio included:

• Increasing their fee-for-service 96110 and 96111 reimbursement rates July 1 to $10.32 and $51.01 from $8.49 and $42.51, respectively.
• Supporting adoption of structured screening in primary care by completing a Developmental Screening Tools and Schedule recommendation and a Physician Referral Tool Kit. 
• Sustaining and spreading improvement activities by developing a strategic plan with the Ohio AAP Chapter to conduct physician education and training on general developmental and autism screening using the evidence-based screening tools Ages and Stages Questionnaire (ASQ) and The Modified Checklist for Autism in Toddlers (M-CHAT) via a series of workshops targeting up to 100 practices; including both pediatricians and family medicine, supported by a grant with the Health Resources and Services Administration (HRSA).
   

The Wisconsin ABCD Screening Academy Project built on existing initiatives and develop statewide training and technical assistance strategies to educate healthcare providers on the integrating of validated, objective screening tools into primary care practices.  Many of these plans were incorporated into the state-wide implementation of BadgerCare+, an effort to expand coverage through a redesign of the state Medicaid program.

Specifically, the ABCD Screening Academy activities in Wisconsin included:

• Supporting improvements in screening practices by developing a screening website for providers, families and other stakeholders seeking to improve the quality of pediatric care. 
• Sustaining and spreading improvements through the creation of an inventory of what professionals are using recommedned screening tools and seeking ongoing funding opportunities such as the CDC's National Center on Birth Defects and Developmental Disabilities (NCBDDD) Research Topic of Interest (RTOI) grant for additional assistance in training family physicians on integrating screening into well child care. 

Prior to ABCD II, Iowa's early childhood efforts focused on day care, early education, and public health services. Since ABCD II, there has been a growing appreciation of the role the private primary health care provider plays in the system. Private health care providers are now invited and engaged in planning and policy efforts at both the state and community levels.

Iowa established three levels of services, focusing on (1) preventive services, including screening, assessment, family risk factors, counseling, and care coordination for all Medicaid eligible children; (2) developmental services, such as problem-based counseling and coordination of care for all Medicaid eligible children identified at risk for developmental or emotional problems; and (3) intensive developmental or mental health services for those children identified in need of therapy.

Minnesota’s ABCD III project, Communities Coordinating for Healthy Development will build on the state’s excellent progress in recent years in the development and coordination of early childhood services and systems.  Well-established partnerships between public agencies as well as between public and private entities and an overlap in staff who work on the various initiatives provide a sound infrastructure for promoting linkages. The strong role of counties in delivering care has enabled communities to tailor services to their unique needs and created wide variability in the operation of early intervention services and access to resources across communities.  Minnesota plans to achieve three objectives through ABCD III: (1) participating clinics will have a systematic process in place for screening, referring and tracking services for children and their families that will include communication between providers and the family, (2) Early Intervention agencies in the pilot communities will receive increased referrals of children and the referrals will be earlier than had previously occurred, (3) families will experience more coordinated care, feel more comfortable about referrals, diagnosis, or lack thereof, and useful anticipatory guidance.

Oklahoma’s ABCD III project, Connecting the Docs: Improving Care Coordination and Delivery of Developmental Screening and Referral Services in Oklahoma, will advance systemic changes to improve outcomes for young children with and at risk for developmental delays.  This initiative builds on existing infrastructure to establish new and strengthen existing linkages among entities serving children and families.  Through its work in the Setting the Stage and ABCD Screening Academy projects Oklahoma has already implemented policy and practice changes that support improved identification of children at risk for developmental delay.  These provide a strong platform to improve linkages between primary care practices and community providers.  In addition, Oklahoma is transitioning to a patient-centered medical home model for delivery of care to Medicaid beneficiaries.  ABCD III project findings will inform the broader medical home work since coordination is key to an effective medical home.  Oklahoma has identified four issues it will address in ABCD III: (1) infrastructure to coordinate isolated initiatives designed to ensure follow-up for referrals, linkage of subsystems, and monitoring of process and outcome measures; (2) consistent single point of contact or consistent service provision infrastructure across communities; (3) process to assure that families of children at risk for delay are connected with appropriate services; and (4) resources and visibility in rural areas.
 

New Mexico participated in the ABCD Screening Academy as a “Setting the Stage for Success” grantee, a project designed to learn from and replicate the North Carolina ABCD Project model for integrating standardized developmental screening into well-child care visits.  Specifically, the ABCD Screening Academy activities  in New Mexico included:

• Revising reimbursement policy to allow providers to bill the 96110 code when a objective, validated screening tool is administered. 
• Proposing to the New Mexico Legislature that structured developmental screening be required under EPSDT.
• Investigating the possibility of purchasing state access to Ages and Stages Questionnaire (ASQ) in both English and Spanish for use by all EPSDT providers.
• Designing a poster series targeting both primary care and other child and family service providers working with young children and parents that promotes standardized developmental screening.
• Sustaining and spreading improvement activities through grant proposals - one which will implement structured screening in 8 additional communities and the other which will enable practices participating in the Developmental Screening Initiative (DSI) to qualify as part of a pediatric quality improvement program.  By mplementing structured screening as part of well child care in this program, providers would meet Part 4 of required recertification guidelines for continued licensure as a pediatrician.     

• Engaging state policy makers in an effort to clarify and/or improve reimbursement policies for developmental screening.
• Reaching out to providers and practices by providing the Ages and Stages Questionnaire (ASQ) screening tool and training to interested practices , thus expanding implementation to a total of four practice sites.
• Sustaining and spreading the ABCD model to additional Montana cities and practices including, the Center on Mental Health, county health departments, child care providers, and pediatric providers, who all began using the Ages and Stages Questionnaire. 

Oregon’s ABCD III project, ABCD for Oregon’s Healthy Kids will build on a number of initiatives designed to promote the healthy development of children.  Specifically, Oregon Medicaid in collaboration with state, professional and community partners will use Medicaid’s quality improvement processes across systems that influence child development, with the goal of defining quality medical home practice for Oregon’s children.  Oregon is in an excellent position to undertake this project—the legislative and executive branches have placed priority on covering all of Oregon’s children and created an integrated Health Authority.  Also, their work in the ABCD Screening Academy catalyzed practice and policy improvements across systems by bringing together primary care, early intervention, and public health.  Oregon has identified two primary issues they plan to address in ABCD III:  (1) capitalize on improvements in the spread of structured screening in primary care and assure sustainable coordination models; and (2) strengthen the relationship between systems of care, including the medical home model.

The Alaska ABCD Screening Academy Project established a statewide stakeholder group, implemented the use of a standardized screening tool in several practices, and worked to identify and implement state policy improvements to support effective screening. Specifically, the ABCD Screening Academy project in Alaska improved structured developmental screening by:

• Recommending a revision in Early Intervention eligibility levels from 50% developmental delays to 25% and requesting additional funding for Part C/Early Intervention services.
• Developing universal referral and feedback forms in demonstration site areas designed to improve the referral and communication process, forms which can be adapted for other areas of the state, and developing resources for parents on "why to follow up with a referral" to be printed and distributed along with other information to primary care offices.
• Spreading the use of validated, objective screening tools by implementing screening in additional sites and sustaining these activities through funding from the Alaska Mental Health Trust.