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New York State New York State Department of Health Department of Health Outcomes of New York’s Outcomes of New York’s Newborn Hearing Screening Program Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A Connie Donohue, M.A., CCC-A
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New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Dec 27, 2015

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Page 1: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

New York State New York State Department of HealthDepartment of Health

Outcomes of New York’s Outcomes of New York’s Newborn Hearing Screening Program Newborn Hearing Screening Program

Lynn Spivak, Ph.D., CCC-ALynn Spivak, Ph.D., CCC-AConnie Donohue, M.A., CCC-AConnie Donohue, M.A., CCC-A

Page 2: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

NIH Consensus ConferenceNIH Consensus ConferenceMarch 1-3, 1993March 1-3, 1993

All newborns should be screened for All newborns should be screened for hearing loss (not just high risk).hearing loss (not just high risk).

Recommended method:Recommended method:– 2 Stage Screen consisting of OAE & ABR2 Stage Screen consisting of OAE & ABR

Page 3: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

New York State Demonstration ProjectNew York State Demonstration Project

1995 – 19981995 – 1998

Purpose: Determine Purpose: Determine the feasibility and the feasibility and

cost effectiveness of cost effectiveness of NBHS in NY State.NBHS in NY State.

Page 4: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

NYS Demonstration ProjectNYS Demonstration Project

7 Hospitals from different regions:7 Hospitals from different regions:– New York CityNew York City– UpstateUpstate– Long IslandLong Island

TEOAE + ABRTEOAE + ABR Tested 69,766 newborns (97% of births)Tested 69,766 newborns (97% of births)

Page 5: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

The Learning Curve: Refer Rates The Learning Curve: Refer Rates (Fails & Misses)(Fails & Misses)

0

1

2

3

4

5

6

7

Year 1 Year 2 Year 3

% % Failed% Missed

Page 6: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

NYS Demonstration ProjectNYS Demonstration ProjectFollow-upFollow-up

NICUNICU WBNWBN TOTALTOTAL

% Fails % Fails ReturnedReturned

80%80% 70%70% 72%72%

% Missed% Missed

ReturnedReturned

34%34% 27%27% 31%31%

Page 7: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

NYS Demonstration ProjectNYS Demonstration ProjectFollow-Up Improvement with TimeFollow-Up Improvement with Time

0

10

20

30

40

50

60

70

80

90

Year 1 Year 2 Year 3

Perc

ent

Retu

rned

% Fail% Miss

Page 8: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

NYS Demonstration ProjectNYS Demonstration ProjectPrevalence of Hearing LossPrevalence of Hearing Loss

Overall Overall 1.96 / 10001.96 / 1000 AdjustedAdjusted 2.80 / 10002.80 / 1000

NICUNICU 8.00 / 10008.00 / 1000 WBNWBN 0.90 / 10000.90 / 1000

Page 9: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

NYS Demonstration ProjectNYS Demonstration Project

COSTCOST

$30 per infant screened$30 per infant screened

Page 10: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Newborn Hearing Screening in Newborn Hearing Screening in New York New York

Review of StatuteReview of Statute

– Chapter 585 of the Laws of 1999Chapter 585 of the Laws of 1999

– Requires the commissioner of health to Requires the commissioner of health to establish a program to screen newborn infants establish a program to screen newborn infants for hearing problemsfor hearing problems

Page 11: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

UNHS: NYS LegislationUNHS: NYS Legislation The commissioner shall--establish a The commissioner shall--establish a

program to screen newborn infants for program to screen newborn infants for hearing problemshearing problems

Incorporate consensus medical guidelinesIncorporate consensus medical guidelines– most cost effective methods for detecting HL as most cost effective methods for detecting HL as

early as possibleearly as possible Program shall provide for follow-upProgram shall provide for follow-up

Page 12: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

UNHS: NYS LegislationUNHS: NYS Legislation Program shall provide for reimbursement of Program shall provide for reimbursement of

health care providers performing screeninghealth care providers performing screening

Hospitals must administer program or Hospitals must administer program or provide a referral for outpatient screeningprovide a referral for outpatient screening

Page 13: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

UNHS: Ad Hoc Advisory UNHS: Ad Hoc Advisory CommitteeCommittee

2 Pediatricians2 Pediatricians 2 Audiologists2 Audiologists 2 Lawyers2 Lawyers

– representing hospital organizationsrepresenting hospital organizations 2 Parents2 Parents 1 Rep from Rural Hospitals1 Rep from Rural Hospitals 1 State Insurance Department Rep1 State Insurance Department Rep Representatives from DOHRepresentatives from DOH

Page 14: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

UNHS: NYS LegislationUNHS: NYS Legislation

Regulations adopted—August 22, 2001Regulations adopted—August 22, 2001 Regulations went into effect October 20Regulations went into effect October 20 thth, ,

20012001

Page 15: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Required Program Components Required Program Components

Conduct inpatient screeningConduct inpatient screening Communication of results to parentsCommunication of results to parents Conduct follow-up screen or referral Conduct follow-up screen or referral

– failsfails– missesmisses

Referral of infants suspected of having Referral of infants suspected of having hearing loss to the Early Intervention hearing loss to the Early Intervention Program (EIP)Program (EIP)

Page 16: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Required Components (2)Required Components (2)

Designate program managerDesignate program manager Provide supervision & training of screenersProvide supervision & training of screeners Maintain & calibrate equipmentMaintain & calibrate equipment Provide adequate space for screeningProvide adequate space for screening Report aggregate data to DOHReport aggregate data to DOH Establish QA protocolsEstablish QA protocols

Page 17: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

EquipmentEquipment

Fully automatedFully automated

No clinical decision making requiredNo clinical decision making required

– ALGOALGO

– EchocheckEchocheck

Page 18: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

DocumentationDocumentation

Inpatient screening resultsInpatient screening results Outpatient screening results known to Outpatient screening results known to

facilityfacility Referrals to EIPReferrals to EIP Issuance of prescription for infants who fail Issuance of prescription for infants who fail

or were missedor were missed

Page 19: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Parent Notification/EducationParent Notification/Education

Brochures supplied by DOH Brochures supplied by DOH » Information for ParentsInformation for Parents

» Your Baby Passed Your Baby Passed

» Your Baby Needs Another ScreeningYour Baby Needs Another Screening

» How to Get Your Baby’s Hearing ScreenedHow to Get Your Baby’s Hearing Screened

– Communication milestonesCommunication milestones– Signs of hearing lossSigns of hearing loss

Inform parents of screen results before Inform parents of screen results before dischargedischarge

Page 20: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.
Page 21: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Early Hearing Detection and Early Hearing Detection and Intervention ProgramsIntervention Programs

Early Hearing Detection and Intervention Early Hearing Detection and Intervention (EHDI) Programs(EHDI) ProgramsNewborn hearing screening is one component Newborn hearing screening is one component

of EHDI Programsof EHDI ProgramsAmerican Academy of Pediatrics Task Force American Academy of Pediatrics Task Force

Page 22: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Components of EHDI Programs Components of EHDI Programs in the USin the US

Universal newborn hearing screeningUniversal newborn hearing screening Effective tracking and follow-up Effective tracking and follow-up Appropriate and timely diagnosis of the hearing lossAppropriate and timely diagnosis of the hearing loss Prompt enrollment in appropriate early interventionPrompt enrollment in appropriate early intervention A medical home for all newbornsA medical home for all newborns Culturally competent family supportCulturally competent family support Elimination of barriers to service accessElimination of barriers to service access

Page 23: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Healthy People 2010Healthy People 2010

Objective 28-11:Objective 28-11:

Increase the proportion of newborns who Increase the proportion of newborns who are screened for hearing loss by age 1 are screened for hearing loss by age 1 month, have audiologic evaluation by age 3 month, have audiologic evaluation by age 3 months, and are enrolled in appropriate months, and are enrolled in appropriate intervention services by age 6 months.intervention services by age 6 months.

Page 24: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

EHDI TimelineEHDI Timeline

Before One Month of AgeBefore One Month of Age– Outpatient re-screening for all failed or missed Outpatient re-screening for all failed or missed

screeningsscreenings Before Three Months of Age:Before Three Months of Age:

– Referral of infants that do not pass an initial Referral of infants that do not pass an initial (inpatient) screening and an outpatient re-(inpatient) screening and an outpatient re-screening to the Early Intervention Program screening to the Early Intervention Program

– Audiological evaluationAudiological evaluation

Page 25: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

EHDI Timeline (2)EHDI Timeline (2)

Before Three Months of AgeBefore Three Months of AgeIf Hearing Loss is ConfirmedIf Hearing Loss is Confirmed– Early intervention servicesEarly intervention services– Parental information and choices about Parental information and choices about

amplification and communication optionsamplification and communication options Before Six Months of AgeBefore Six Months of Age

– Continue early interventionContinue early intervention– Additional consultation as neededAdditional consultation as needed

Page 26: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Newborn Hearing ScreeningNewborn Hearing Screening in New York in New York

Highlights of program developmentHighlights of program development– Funding in 2002 Governor’s budgetFunding in 2002 Governor’s budget– Guidance memorandumGuidance memorandum– Ongoing technical assistanceOngoing technical assistance– Screening ratesScreening rates

Page 27: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Hospital Newborn Hearing Hospital Newborn Hearing Screening ProgramsScreening Programs

Options for administering programsOptions for administering programs– Screen infants prior to discharge and conduct Screen infants prior to discharge and conduct

outpatient re-screens for infants who referoutpatient re-screens for infants who refer– Screen infants prior to discharge and refer Screen infants prior to discharge and refer

infants who do not pass to a different facility infants who do not pass to a different facility for outpatient re-screenfor outpatient re-screen

– Refer all infants for hearing screening after Refer all infants for hearing screening after discharge (facilities with 400 or fewer births discharge (facilities with 400 or fewer births per year)per year)

Page 28: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Newborn Hearing Screening Newborn Hearing Screening Data Reporting RequirementsData Reporting Requirements

All maternity hospitals and birthing centers All maternity hospitals and birthing centers submit quarterly reports to the Department submit quarterly reports to the Department of Healthof Health– Aggregate dataAggregate data– Due 90 days after the close of the quarterDue 90 days after the close of the quarter

Page 29: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Data Reporting: Data PointsData Reporting: Data Points

Number of inpatient screens conductedNumber of inpatient screens conducted» (pass, fail)(pass, fail)

Number of missed inpatient screensNumber of missed inpatient screens Number of outpatient screens conductedNumber of outpatient screens conducted

» (pass, fail)(pass, fail)

Number of refusalsNumber of refusals

Page 30: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Date Reporting: Data DictionaryDate Reporting: Data Dictionary

Inpatient Initial Screening Final ResultInpatient Initial Screening Final Result» Passed: Number of infants who passed on first Passed: Number of infants who passed on first

screen or following subsequent screening prior to screen or following subsequent screening prior to dischargedischarge

» Failed – Unilateral: Number of infants who did not Failed – Unilateral: Number of infants who did not pass the hearing screening in one ear prior to pass the hearing screening in one ear prior to dischargedischarge

» Failed – Bilateral: Number of infants who did not Failed – Bilateral: Number of infants who did not pass the hearing screening in both ears prior to pass the hearing screening in both ears prior to dischargedischarge

» Refused: Number of infants for whom the guardian Refused: Number of infants for whom the guardian declined inpatient screeningdeclined inpatient screening

Page 31: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Data Reporting: Data Points (2)Data Reporting: Data Points (2)

Number of referrals for outpatient screeningNumber of referrals for outpatient screening Number of results returned to the facility by Number of results returned to the facility by

other providers conducting outpatient other providers conducting outpatient screensscreens– (pass, fail)(pass, fail)

Number of at-risk infants referred to the Number of at-risk infants referred to the Early Intervention Program for follow-upEarly Intervention Program for follow-up

Page 32: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Data Reporting: Data DictionaryData Reporting: Data Dictionary

Number of Newborns Receiving Outpatient Number of Newborns Receiving Outpatient Hearing Screenings for Births in Reporting Hearing Screenings for Births in Reporting PeriodPeriod

» Referred: Missed Initial: Applicable to infants Referred: Missed Initial: Applicable to infants issued prescriptions for outpatient newborn hearing issued prescriptions for outpatient newborn hearing screening due to being missed during inpatient stayscreening due to being missed during inpatient stay

» Referred: Failed Initial: Applicable to infants who Referred: Failed Initial: Applicable to infants who were issued prescriptions for newborn hearing were issued prescriptions for newborn hearing screening due to failing initial inpatient screeningscreening due to failing initial inpatient screening

Page 33: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Data Reporting: Data Points (3)Data Reporting: Data Points (3)

Number of Newborns for Reporting Period Number of Newborns for Reporting Period with a Failed Initial Screen and No Re-with a Failed Initial Screen and No Re-screening Results Returned to the Facilityscreening Results Returned to the Facility– Fewer than 75 days post dischargeFewer than 75 days post discharge– 75 days or greater post discharge75 days or greater post discharge

» Referred to early interventionReferred to early intervention

» Not referred to early intervention due to parental Not referred to early intervention due to parental objectionobjection

» Lost to follow-upLost to follow-up

Page 34: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Newborn Hearing Screening Newborn Hearing Screening Progress in New YorkProgress in New York

Babies screened for hearing loss prior to Babies screened for hearing loss prior to hospital dischargehospital discharge

– October – December 2001: 85%October – December 2001: 85%– January – December 2002: 96.44%January – December 2002: 96.44%– January – December 2003: 98.6%*January – December 2003: 98.6%*

*based on newborn hearing screening data*based on newborn hearing screening data

Page 35: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Newborn Hearing Screening Newborn Hearing Screening Progress in New YorkProgress in New York

2003 Statistics2003 Statistics– Number of babies screened: 230,139Number of babies screened: 230,139– Refer rate: 4.2%Refer rate: 4.2%– Percentage of babies receiving a re-screen: Percentage of babies receiving a re-screen:

73.2% 73.2% – Percentage of babies with suspected hearing Percentage of babies with suspected hearing

loss: 0.51%loss: 0.51%– Referrals to early intervention: 308Referrals to early intervention: 308

Page 36: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Children With a Diagnosis Upon Children With a Diagnosis Upon Referral to the EIPReferral to the EIP

Page 37: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Children Referred to EI with a Children Referred to EI with a Diagnosis of Hearing LossDiagnosis of Hearing Loss

Page 38: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Children Referred to EI with a Children Referred to EI with a Diagnosis of Hearing Loss Diagnosis of Hearing Loss

Page 39: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Early Intervention Guidance Early Intervention Guidance Memorandum 2003-03Memorandum 2003-03

Newborn Hearing ScreeningNewborn Hearing Screening– General informationGeneral information– Role of maternity hospitalsRole of maternity hospitals– Role of the Early Intervention Program Role of the Early Intervention Program

» Referral processReferral process

» Procedural aspectsProcedural aspects

» Early intervention servicesEarly intervention services

Page 40: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Referral to Early Intervention Referral to Early Intervention

Following newborn hearing screeningFollowing newborn hearing screening

1.1. After an infant fails two hearing After an infant fails two hearing screenings screenings

2.2. When an infant fails initial hearing When an infant fails initial hearing screening and does not receive a follow-screening and does not receive a follow-up screening within 75 days after up screening within 75 days after dischargedischarge

Page 41: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Referral to Early InterventionReferral to Early Intervention

Children are referred to the Early Children are referred to the Early Intervention Official in their county of Intervention Official in their county of residenceresidence– Primary referral sources must refer children Primary referral sources must refer children

under age three with suspected or confirmed under age three with suspected or confirmed developmental delay or disability to the Early developmental delay or disability to the Early Intervention Official unless the parent objectsIntervention Official unless the parent objects

Page 42: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Early InterventionEarly Intervention

Part C of IDEA is an important resource for Part C of IDEA is an important resource for infants with hearing loss and their familiesinfants with hearing loss and their families– Audiology services are included in Early Audiology services are included in Early

Intervention Program regulations Intervention Program regulations (10 NYCRR Section 69-4.1(k)(2)(iii)(a-f))(10 NYCRR Section 69-4.1(k)(2)(iii)(a-f))

Page 43: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Considerations for Early Considerations for Early InterventionIntervention

For children with hearing loss and their For children with hearing loss and their families...families...– Family SupportFamily Support

– Technology DecisionsTechnology Decisions

– Communication ChoicesCommunication Choices

Page 44: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Other ResourcesOther Resources

National Center for Hearing Assessment and Management National Center for Hearing Assessment and Management (NCHAM)(NCHAM)– Web site: Web site: www.infanthearing.orgwww.infanthearing.org

American Speech-Language-Hearing Association (ASHA)American Speech-Language-Hearing Association (ASHA)– Web site: Web site: www.asha.orgwww.asha.org

New York State Department of HealthNew York State Department of Health– Web site: Web site: http://www.health.state.ny.ushttp://www.health.state.ny.us

» Family & Community Health, Infants & Children, Family & Community Health, Infants & Children, Early InterventionEarly Intervention

Page 45: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Good work,but I think we mightneed just a little more detail righthere.

Implementing Effective Screening Programs

Then amiracleoccurs

out

Start

Page 46: New York State Department of Health Outcomes of New York’s Newborn Hearing Screening Program Lynn Spivak, Ph.D., CCC-A Connie Donohue, M.A., CCC-A.

Thank you Thank you

New York StateNew York StateDepartment of HealthDepartment of Health