The Assuring Better Child Health and Development Initiative (ABCD) was formed in 2000 with a focus on supporting young children’s healthy development because there was strong evidence and growing recognition that early intervention can change the trajectory of a child’s life. Children at risk for developmental delay were not being identified as early as they could be and, even after identification, many children waited too long to receive services. The American Academy of Pediatrics was also near release of a statement that made explicit recommendations about surveillance and use of standardized screening tools to help identify developmental delays. The time was right for states to engage with this critical issue.
Since 2000, NASHP and The Commonwealth Fund have worked with states to improve identification and treatment of children at risk for developmental delay by convening three learning collaboratives and the ABCD Screening Academy designed to spread promising practices that improve identification of children at risk for developmental delay. During this time we have worked with Medicaid-led public/private partnerships from 25 states, the District of Columbia and Puerto Rico. Almost all participating states have made policy and practice changes—and many continue to work to improve the delivery of child development services. As the ABCD III Collaborative completes its work, I paused to reflect on these achievements and on what remains to be accomplished.
- Despite tough economic times and state budget challenges, ABCD states have been willing to invest resources to support healthy child development. As of April 2011, at least 32 states (mostly ABCD states) had implemented policies that improve identification of delays by fostering standardized developmental screening. As a whole, the ABCD states made improvements to policies governing benefits and eligibility, reimbursement, and program performance. Also, state Medicaid, maternal and child health, early intervention, and mental health programs all improved policies. For example,
- Iowa, Utah, and Minnesota have clarified that providers may use the DC:0-3 diagnosis classification system to diagnose young children, crosswalk that diagnosis to a DSM diagnosis and bill Medicaid for treatment.
- ABCD III states (Arkansas, Illinois, Minnesota, Oklahoma, Oregon) have developed referral and feedback forms and templates that meet both health and education privacy and regulatory requirements. These forms allow bi-directional communication between primary care, Early Intervention, and other service providers that did not previously occur.
- ABCD states forged new and strengthened existing partnerships to promote healthy child development. A key feature of ABCD has been the collaborative partnership between payers (Medicaid) and providers (pediatricians, nurses, mental health professionals) to improve identification, referral and treatment for young, low-income children at risk of developmental problems. For example, Medicaid agencies and AAP chapters in Illinois and Minnesota jointly developed screening and care coordination projects that provided credit for physicians to meet their Maintenance of Certification (MOC) for board re-certification. Also, an external evaluation of ABCD I categorized it as a successful collaboration among Medicaid and other state agencies: “interagency barriers were broken down and often intractable bureaucracies changed their behaviors.”1
- The work of the ABCD states influenced national policy. ABCD measurement efforts, in particular, have strengthened and been strengthened by national efforts. The developmental screening measure developed by the Child and Adolescent Health Measurement Initiative (CAHMI) in partnership with NASHP and ABCD states was included in the CHIPRA core measure set and endorsed by the National Quality Forum. In 2010 CMS awarded 10 CHIPRA quality grants. Most grantee states are seeking to improve the developmental screening measure and/or develop and test children’s electronic medical records to support measurement. Others are seeking to advance screening.
- ABCD has had a lasting effect in many states and continues to produce results. Most strikingly, all four of the states that participated in the first ABCD project, which ended in 2003, continue some aspect of the improvements they implemented during that project. For example:
- Utah’s pre-natal-5 nurse home visiting program for children at risk of developmental delay is still in place.
- The developmental screening practices piloted in one Community Care of North Carolina network have spread to all 14 networks.
- ABCD states are improving the delivery of child development services. All five states in the second ABCD collaborative reported that participating primary care practices dramatically increased their use of standardized screening tools-and four of the states reported screening rates of over 75% among these practices. Further, the CAHMI found that although children are still not being screened at the rate they should be, children with public insurance are more likely to receive a developmental screening (23.6%) than either children with other coverage (17.8%) or uninsured children (14.8%).
Over the past 12 years I have been impressed with the dedication and creativity of ABCD state team members and stakeholders. Over the past three years the members of the final ABCD collaborative (Arkansas, Illinois, Minnesota, Oklahoma, and Oregon) have worked on ways to facilitate referral and treatment by improving feedback loops between primary care and community services, especially Early Intervention programs. They have developed policies that support coordination, piloted practice improvements in communities, and developed new infrastructures for information sharing. Their emerging communication systems are the underpinning of any effort to improve care coordination, and thus critical to broader delivery system reform and innovation, such as medical homes and ACOs. At NASHP, we will continue to distill the strategies and lessons learned from these states’ efforts to help all states tackle this critical but daunting issue.
C. A. Berry, G. S. Krutz, B. E. Langner et al., “Jump-Starting Collaboration: The ABCD Initiative and the Provision of Child Development Services Through Medicaid and Collaborators,” Public Administration Review, May/June 2008 68(3):480–90.
Jill Rosenthal, NASHP Program Director, contributed to this blog.