NC Preschool Coordinators Institute November 20, 2013
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NC Preschool Coordinators
Institute
November 20, 2013
Participants will better understand:
• The purpose of the ABCD project &
updates to the communication plan
• How to implement embedded instruction
practices into classroom routines with
fidelity
• Their own data for Child Find and
educational environments (LRE)
Setting the Stage for Success…
Assuring Better Child Health & Development “ABCD”
The NC ABCD Project: 2000 - Present
Marian Earls, MD,
FAAP
Director of Pediatric
Programs
Quality Improvement in Primary Care Practice
Developmental Screening & Surveillance…..
The Solution: (1) Develop a “best practices” comprehensive
community model for replication – The model built on
North Carolina’s “Physician Driven”, enhanced primary care, case
management program, Community Care of North Carolina, and
characterized by two major components:
Introduction & integration of a standardized, validated screening
tool (ASQ or PEDS) at selected well-child visits, that is practical
and that works;
Collaboration with local and state agency staff and families in
developing this system for identifying and serving children.
The Solution (cont.):
(2.) Formed a State Advisory Group – The group is
comprised of leadership from key agencies who have
the capability of making policy changes.
• Medicaid
• Early Intervention Part C
• Public Health
• State ICC
• Department of Public
Instruction: Preschool
• Smart Start
• Family Support Network
• NC Pediatric Society
• NC Academy of Family Practice
Strategic Components Implemented within the infrastructure of Community Care of NC (CCNC)
• Quality improvement project in primary care with quarterly
data sharing and review
• Data: 8 years of claims reporting, incorporated into CCNC’s QMAF in 2012
• Formation of State Advisory Group that involved leadership from the NC AAP Chapter and AFP Chapter
• Aligned with other CCNC quality initiatives: Mental Health Integration, Medical Home, and CHIPRA Child Health Quality Demonstration Grant
Strategic Components Community Linkages & Systems Building
• Active/engaged State Advisory Group representing
CCNC, Medicaid, PCC’s, Part C, Family Support, Public
Health, Public Instruction
• Aligning goals with state partners: Part C, Preschool and
Department of Public Instruction, Smart Start
• Standardized referral protocols and forms with Part C and
Part B preschool
Assuring Better Child Development (ABCD Project) • Began in P4CC network, now statewide
• Screening and surveillance with parents as experts on
their child
• Elicits parent concerns
• Builds ongoing relationship between parents and the
Primary Care provider
• Promotion Healthy Development
• Early Identification
Cherokee
Graham
Swain
Clay Macon
Jackson
Haywood
Madison
Buncombe
Henderson
McDowell
Rutherford
Polk
Burke
Cleveland
Watauga
Caldwell Alexander
Catawba
Lincoln
Gaston
Ashe
Wilkes
Alleghany
Surry
Yadkin
Iredell
Mecklenburg
Union
Stanly
Cabarrus
Rowan
Davie
Stokes
Forsyth
Davidson
Anson
Rockingham
Guilford
Randolph
Montgomery
Richmond
Caswell
Chatham
Orange
Person
Lee
Moore
Hoke
Scotland
Robeson
Cumberland
Harnett
Wake
Franklin
Warren
Johnston
Sampson
Bladen
Columbus
Brunswick
Pender
Duplin
Wayne
Wilson
Nash
Halifax
Northhampton
Edgecombe
Pitt
Greene
Lenoir
Jones
Onslow
Craven
Pamlico
Beaufort Hyde
Martin
Bertie
Hertford
Gates
Washington Tyrrell
Dare
Ala
mance
Durham
Granville
Hanover
Chow
an
a
r
Source: CCNC 2011
Legend AccessCare Network Sites Community Care Plan of Eastern Carolina AccessCare Network Counties Community Health Partners Community Care of Western North Carolina Northern Piedmont Community Care Community Care of the Lower Cape Fear Northwest Community Care Carolina Collaborative Community Care Partnership for Health Management Community Care of Wake and Johnston Counties Community Care of the Sandhills Community Care Partners of Greater Mecklenburg Community Care of Southern Piedmont Carolina Community Health Partnership
NC Policy Change
Medicaid changed policy (Health Check), effective 7/1/2004,
requiring a valid, standardized developmental screening tool
when screening children at:
6, 12, 18 or 24months, and
3, 4, & 5 year old visit.
Effective 7/1/2010 Autism screening with MCHAT
required at 18 and 24 month well-visits
Public Health system (Child Health) transitioned
clinics to a menu of standardized, valid,
developmental screening tools in 2003
NC ABCD- began, 2000
Currently:
• Eighth year of quarterly reporting on developmental screenings by practice, county and network (~ 340,000 claims/year)
• Greater than 90% of primary care practices are screening.
• 79.5% of exams for 0-5 year olds include a developmental screening
• Increase in referrals to Part C since 2003 from 3400 to >20,000 annually
• Physicians have become the largest single referral source for Early Intervention
National Trends for Developmental Screening and Follow-up
Implications For
NC ABCD
National Trends for Screening and Surveillance ABCD Commonwealth Fund Initiatives since 2000:
• ABCD I (2000–2003)
• ABCD II (2003–2006)
• Setting the Stage for Success (2006–2007)
• ABCD Screening Academy (July 2007)—involving 23
states
• ABCD III (2009-2012)
National Trends for Screening and Surveillance
AAP: 2001 & 2006 Policy Statements, Task Force on
Mental Health, Bright Futures, 2007 Autism Screening
Guidelines
Rethinking Well-Child Care (AAP and Commonwealth)
Tiered Well-Child Care (Commonwealth)
SAMHSA—screening for social-emotional development
Early Childhood Comprehensive Systems Grants (MCHB)
Medical Home (AAP)
National Trends for Screening and Surveillance
• Measure 8 of the Core Quality Measures for Child Health,
from CMS and AHRQ; being implemented by CHIPRA
states now, required 2015
• Pediatric Measure Center of Excellence Expert Work
Group: Developmental Screening and Follow-up
• NASHP Strengthening Primary Care and Care
Coordination for Healthy Child Development, February 7
and 8, 2013. Meetings with Federal Agencies. Issues:
information sharing (PCC and Part C), state care
coordination activities, spread of ABCD strategies and
needed federal support, need for national measure, HER
needs
State Medicaid Requirements and Reimbursement Policies
On Developmental Screening,
April 201112
Red: State Medicaid program requires standardized developmental screening as part of well-child
exams and pays an additional fee beyond the usual well-child care reimbursement for this screening.
(8)
Blue: State Medicaid program requires standardized developmental screening as part of well-child
exams, but does not pay an additional fee beyond the usual well-child care reimbursement for this
screening (6)
Yellow: State Medicaid program pays an additional fee beyond the usual well-child care
reimbursement for standardized developmental screening, but does not require this screening as part
of well-child exams (18)
Green: State Medicaid program does not require standardized developmental screening as part of
well-child exams and does not pay an additional fee beyond the usual well-child care reimbursement
for the screening. (7 states and D.C.)
White: State did not respond. (11)
1 The Colorado Medicaid program requires the use of a standardized screening tool, but the screening is
not required to be completed at a well child check. It can be completed at other times of the year (e.g. sick
child visits). It is paid under a separate code. 2 The Kentucky Medicaid program reimburses for screening, but not during an EPSDT well child exam.
NH MA
ME
NJ
CT RI
DE
VT
NY
DC
MD
NC
PA
VA WV
FL
GA
SC
KY
IN OH
MI
TN
MS AL
MO
IL
IA
MN
WI
LA
AR
OK
TX
KS
NE
ND
SD
HI
MT
WY
UT
CO
AK
AZ
NM
ID OR
WA
NV
CA
PMCoE DSF: Current Draft
1. Consistent performance of developmental screening
– A screen before 12 months
– A screen between 12 and 24 months
– A screen between 24 and 36 months
2. Follow-up with patient family after developmental
screening (discussion of results)
3. Follow-up referral after positive developmental screen
4. Developmental follow-up referral tracking
Ongoing Challenge
Quality of screening and referral
• Training of PCC’s – community resources for referral,
building relationships for effective linkages
• Establishing reliable systems for communication and
feedback (FERPA issues in particular)
• Keeping ABCD “on the radar” at practice and state level
Primary Care Physician (PCP) is notified ASAP about the evaluation result
and service plans in order to have a follow-up with the family.
PCP shares results of Audiological Evaluation and other referrals (if any)
with the CDSA as soon as results are reported.
Notes:
Autism specific evaluations and/or
confirmation of an autism diagnosis are
influenced by the age of the child and
findings; younger children and those with
less significant symptoms are more
difficult to diagnose.
MCHAT is Positive (+) OR Autism Surveillance
yields 2 or more + risk factors
If Global Developmental
Delay, Intellectual
Disability is present, or
Genetic or Neurologic
disorder is suspected
CDSA Audiology Evaluation
Consider referral to
D & B Pediatrician
Geneticist
Neurologist
Eligibility evaluation
If developmental delay or
established condition found
IFSP
Further Autism-specific
evaluation as needed
Continued Case
Management, IFSP
Continued Direct Services
as indicated
No ASD or
Developmental Delay
found
CSC or other community
services
(if renewed concern re-
refer)
Primary Care Autism Screening Referral Process for Infants and Toddlers
Referral Form Developmental Screening & Surveillance
Name of Child: Date of Birth: /___/_____Age: Sex: Address: Medicaid ID #: Insurance: Social Security: Parent/ Guardian Name: Home Phone: Work Phone: Race: Primary Language:
Developmental/Interdisciplinary Referral:
Concerns: Screening Tool: ASQ PEDs MCHAT ASQ-SE Other (Please Name)
The ASQ or PEDS and/or MCHAT scoresheet is attached.
I have discussed this referral with parent(s) Referred By: Phone: PCP Office: Fax:
(Insert Letterhead Identification Here)
North Carolina Physician to Preschool Exceptional Children
Program Notification Process Chart For Children 3 to Pre-Kindergarten 5 Years of Age
e.g., Developmental Delays, MCHAT is Positive (+) OR Autism Surveillance
yields 2 or more + risk factors; ASQ or PEDs scores are raised
Physician informs family
of LEA services
, Physician provides family with
Child Find information from
school system
Referral for child service
coordination via health
department
(if appropriate)
Direct contact made between school system & family • Interview parents about child development concerns
• School system obtains existing screenings, observations, etc.
• Suggested Interventions offered to family
• School system or parent may initiate a referral
Eligibility determination & IEP developed, if eligible
• parental consent for services obtained, if eligible
Services begin
School system sends follow-up
information to physician
• With consent for release of
confidential information
School system conducts assessment or proceeds to
eligibility determination
Process stopped- NO EVALUATION • Parent denies consent to make written referral
• School system may utilize procedural
safeguards to pursue evaluation.
• No educational concerns identified
Process stopped • Parent denies consent for services
• Assessments reveal no educational concerns
• Not eligible for special education
NO
Physician sends notification and parental release of
information form
• Contact information
• Signed release of information
• Health screening; including vision and hearing
• Developmental screening
• Behavioral health screening
• Evaluation(s) in process
School system or parent initiates referral • If school system rejects referral, parent may make a
written request
• Parent signs informed consent to evaluate
• 90 day timeline begins
YES
To be faxed to the Medical Home at completion of child’s assessment EARLY INTERVENTION FEEDBACK TO THE MEDICAL HOME
To be completed by the Medical Home
Child’s Name_____________________________________ Medical Home/PCP ____________________________Fax:______________ Child’s DOB ________________Parent /Guardian______________________________________________________________________ Address _________________________________________________________________Phone: ________________________________
CDSA/Preschool Contact: ___________________________________________________Phone:________________________________ Date of referral (CDSA)/date of notification (preschool program)___________________________________________________________
To be completed by the CDSA To be completed by the EC Preschool Program
Why the medical home referred?
At-risk score(s):
o ASQ/PEDS
o MCHAT
o ASQ-SE
Established Condition (Specify below):
o Congenital Anomaly/Genetic Disorder/Inborn Errors of Metabolism
o TORCH (Congenital Infections)
o Autism
o Reactive Attachment Deprivation/Maltreatment Disorder of Infancy
o Hearing Loss
o Visual Impairment
o Neurologic Disease
o Neonatal Conditions (<27 weeks, ELBW, IVH, seizures, stroke, meningitis, etc.
Parent Concern____________________________________
Entry Evaluation Date:______________________________
Why the medical home sent the notification?
At-risk score(s):
o ASQ/PEDS
o MCHAT
o ASQ-SE
Condition that adversely impacts educational performance. (Specify below):
o Speech and Language Impairment
o Developmental Delay/Atypical Behavior
o Autism
o ADHD
o Orthopedically Impairment
o Visually Impairment
o Hearing Impairment
o Other
School System Screening date:________________________
CDSA/EC Preschool Program - results from above: (check all that apply) _______ Eligible (based on): ______________________________________________________________________________ _______ Ineligible (note reason): ___________________________________________________________________________ _______ No Evaluation Done: Parent unreachable_________, Did Not Keep Appointment__________, Declined Services___________
Services on IFSP______ or IEP______: o Service coordination (IFSP)
o Specialized Instruction on the IFSP or IEP
o Speech and Language Therapy
o Physical Therapy (PT)
o Occupational Therapy (OT)
o Other (specify)__________________________
Recommended additional community services: o CC4C
o Family Support Network (FSN)
o Head Start
o NC PreK Program
o Parents as Teachers
o Other (specify):________________
Preschool Educational
Environments
“Least Restrictive Environment”
Where do we serve them?
In the Least Restrictive Environment……
– Inclusive classes are called “regular early
childhood program” or RECP
– Self Contained Settings
– Home
– Service Provider Location
NO
If NO, determine the following: Is the child attending a special education program?
YES
If YES, determine the following: How many hours does the child attend a regular early
childhood program?
If at least 10 hours per week: Where does the child receive the majority of hours of special education and related services? A1 = In the regular education program A2 = In some other location.
If less than 10 hours per
week: Where does the
child receive the majority
of hours of special
education and related
services?
B1 = In the regular
education program
B2 = In some other
location
If NO, Is the child receiving the majority of special education and related services in the residence of the child’s family or caregiver?
At least 10 hours per week
Less than 10 hours per week
If YES, C1 = Special Education Class C2 = Separate School C3 = Residential facility
If NO, D2 = Service Provider location or some other location that is not in any
other category
If YES, D1 = Home
A Regular Early Childhood Program is a program that includes a majority (at least 50 percent) of nondisabled children (i.e., children not on IEP’s). This category may include, but is not limited to: •Preschool classes, public or private •Group child development center or child care
A Special Education Classroom includes a majority (at least 50%) of children with disabilities (i.e., children on IEPs). Separate school designed for children with disabilities. Residential school or medical facility, inpatient
Is the child attending a regular early childhood program?
Decision Tree for Preschool Educational Environments
30
What is the child’s setting?
A. RECP in location
B. RECP another location
C. Service Provider Location
31
RECP in lo
catio
n
RECP another l
ocatio
n
Service
Pro
vider L
ocatio
n
0% 0%0%
Child attends NC PreK class and
receives speech therapy only; clinician
removes child from class most of the time.
What is the child’s setting?
A. RECP in location
B. RECP another location
C. Service Provider Location
32
RECP in lo
catio
n
RECP another l
ocatio
n
Service
Pro
vider L
ocatio
n
0% 0%0%
Child attends child care and parents drive
child to speech therapy session at an
elementary school two days a week for
30 minute sessions.
What is the child’s setting?
A. RECP in location
B. RECP another location
C. Service Provider Location
33
RECP in lo
catio
n
RECP another l
ocatio
n
Service
Pro
vider L
ocatio
n
0% 0%0%
Child attends faith based PreK class
and receives speech therapy only;
clinician removes child from class some
of the time to practice new skills, but
works in class most of the time
What is the child’s setting?
A. RECP in location
B. RECP in another location
C. Self Contained Class
34
RECP in lo
catio
n
RECP in an
other l
ocatio
n
Self Conta
ined C
lass
0% 0%0%
Child attends a part day special ed.
class in the morning and then goes to a
child care program for the afternoon
Is this the truth?
A. False
B. True
35
False
True
0%0%
Child who attend q full day self-
contained PreK class and then goes
to after/before school care should
be coded as separate special ed.
class
How do we measure our progress?
• By determining the total number of children
in each of the settings and calculating two
summary statements.
• Federal government requires that we
include 5 year olds in Ktg. who have not
turned 6 by December 1st.
Cross-walk school aged setting to
PreK settings for 5 yr. olds/Ktg.?
Kindergarten Setting Preschool Setting
Regular- 80% or more of the time with
nondisabled peers
Regular early childhood setting (RECP)
with majority of services in the RECP
setting
Resource- 40% to 79% of the time with
nondisabled peers
Regular early childhood setting (RECP)
with majority of services in another
location
Indicator 6: Percent of children aged 3
through 5 with IEPs attending:
– A. Regular early childhood program and
receiving the majority of special education and
related services in the regular early childhood
program; and
– B. Separate special education class, separate
school or residential facility.
(20 U.S.C. 1416(a)(3)(A))
Summary Statement Calculations
• Summary Calculation A =
RECP A1 + RECP B1
all children
• Summary Calculation B = Separate class + Separate School + Residential
all children
Indicator 6 data
December 1, 2011 headcount
Baseline Data for FFY 2011-2012
Data from 5 year olds in Ktg.
appeared to improve the state’s
inclusion rates
A. True
B. False
True
False
0%0%
Indicator 6 Targets- setting
baselines based on 2011 data
• Summary Calculation A = 51.5
(increase inclusion)
• Summary Calculation B = 20.5
(decrease separate settings)
Indicator 6 data
December, 2012 headcount
49.88%
21.20%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
A. A Regular Early Childhood Program (RECP) and receiving themajority of special education and related services in the regular
early childhood program.
B. A separate special education class, separate school or residentialfacility.
North Carolina Educational Environments Ages 3-5, December 1, 2012 All Children 3-5 Including 5 year olds in Kindergarten
Indicator 6, Percent of Children:
51.5
20.5
Draft
Did the state meet the targets?
A. Yes
B. No
YesNo
0%0%
48.12%
10.15%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
A. A Regular Early Childhood Program (RECP) and receivingthe majority of special education and related services in the
regular early childhood program.
B. A separate special education class, separate school orresidential facility.
LEA Educational Environments Ages 3-5, December 1, 2012 All Children 3-5 Including 5 year olds in Kindergarten
Indicator 6 -- Percent of Children:
51.5
20.5
Draft
Did your LEA meet the targets?
A. Yes
B. No
YesNo
0%0%
Breaking down the data
To help make sense of it and to
explain it to others
Just looking at PreK data
37.84%
23.53%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
A. A Regular Early Childhood Program (RECP) and receiving themajority of special education and related services in the regular
early childhood program.
B. A separate special education class, separate school or residentialfacility.
North Carolina Educational Environments Ages 3-5, December 1, 2012
Children in Pre-K Excluding Children in Kindergarten Percent of Children:
Draft
Comparing your LEA data to the
State data for PreK for LRE
A. Greater than the state
B. Less than the state
C. Same as the state
Greate
r than th
e state
Less
than th
e state
Same as t
he state
0% 0%0%
My LEA data was…….
Comparing your LEA data to the
State data for PreK for Self-contained
A. Greater than the state
B. Less than the state
C. Same as the state
Greate
r than th
e state
Less
than th
e state
Same as t
he state
0% 0%0%
My LEA data was…….
73.70%
16.00%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
A. A Regular Early Childhood Program (RECP) and receiving themajority of special education and related services in the regular
early childhood program.
B. A separate special education class, separate school or residentialfacility.
North Carolina Educational Environments Ages 3-5, December 1, 2012
5 year olds in Kindergarten Percent of Children:
Draft
Comparing your LEA data to the State
data for 5 year olds in Ktg. for LRE
A. Greater than the state
B. Less than the state
C. Same as the state
Greate
r than th
e state
Less
than th
e state
Same as t
he state
0% 0%0%
My LEA data was…….
Comparing your LEA data between 5
year olds in Ktg and PreK childern
A. Higher than for PreK
children
B. Lower than for PreK
children
C. The same
Higher t
han for P
reK ch
i...
Low
er than fo
r Pre
K chil.
..
The sam
e
0% 0%0%
Rates for inclusive settings for 5 year
olds in Ktg were……..
Comparing your LEA data between 5
year olds in Ktg and PreK children
A. Higher than for PreK
children
B. Lower than for PreK
children
C. The same
Higher t
han for P
reK ch
i...
Low
er than fo
r Pre
K chil.
..
The sam
e
0% 0%0%
Rates for self-contained settings for Ktg
children were……
Writing the CIPP
• Describe the trends in your data
• Develop a hypothesis about the trends
• Identify one to two major actions steps you
can develop to improve your program
Explaining the data relative to
size of LEA
A. Yes
B. No Yes
No
0%0%
When comparing the state’s target’s to
an LEA’s summary statements, could
the difference be explained by the
fact that the number of children in the
LEA data set was very small and could
be influenced by individual child cases
rather than overall program
performance?
For small, medium, or big LEAs
A. True
B. False
True
False
0%0%
Do you think you could develop
program improvement goals based
on analysis of the percent of children
in each setting?
For small LEAs…..
A. True
B. False
True
False
0%0%
Do you think you could develop
program improvement goals based
on the comparison between your
5 year olds in Ktg and PreK?
Child Find
65
……………….just find me!
66
2102 10%
6359 31%
1662 8%
1209 6%
1369 7%
2321 12%
5362 26%
Physicians
Infant-Toddler Program
Head Start NC Pre-K Program
Child Care
Other
Parents
North Carolina Child Find Program 2011-2012 Total Number of Notifications and Parent Referrals
N = 20, 384
1903 10%
6453 33%
1825 9%
1304 7%
1390 7%
2219 12%
4197 22%
North Carolina Child Find Program 2012-2013
Total Number of Notifications and Parent Referrals N = 19, 291
Physicians
Infant-Toddler Program
Head Start NC Pre-K Program
Child Care
Other
Parents
Year
December 1
Headcount
April 1
Headcount
Percent
Change
2005-2006 11,689 15,179 +30%
2006 -2007 11,956 15,037 +26%
2007-2008 11,859 14,716 +24%
2008 -2009 11,503 14,392 +25%
2009-2010 12,166 15,079 +24%
2010-2011 12,363 15,482 +25%
2011-2012 12,607 15,560
+24%
2012-2013 12,424 15,317 +24%
Data Source: NC Comprehensive Exceptional Children Accountability
System
Preschool Exceptional Children Child Find Trends
Questions?
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