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Policy Innovation Profile

State Medicaid Program Adopts Multiple Policies to Significantly Increase Screening Rates and Enhance Access to Services for Young Children at Risk of Developmental Disabilities


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Snapshot

Summary

The Oregon Health Authority, which oversees the Oregon Health Plan (the State Medicaid program), implemented a series of policy changes to emphasize and promote earlier detection, more effective referrals, and better coordination of care for pediatric patients with developmental delays. Key changes include encouraging contracted health plans to implement projects to improve screening rates, modifying State standards for patient-centered medical homes to emphasize the special developmental needs of children, and instituting a data-sharing program to formalize and strengthen care coordination and improve performance tracking. Collectively, these policy changes have encouraged many managed care organizations to focus on this issue, significantly increased screening rates for developmental delays, and enhanced access to early intervention services.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of screening rates for developmental delays, along with post-implementation data on the number of managed care organizations participating in a quality improvement project and anecdotal reports from providers and parents about the program's impact on access to early intervention services.
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Developing Organizations

Oregon Health Authority
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Date First Implemented

2008
Work on the policy changes began in 2008, with implementation beginning in 2009 and being completed in 2011.begin pp

Patient Population

Vulnerable Populations > Children; Disabled (developmentally); Age > Infant (1-23 months); Insurance Status > Medicaid; Age > Preschooler (2-5 years)end pp

Problem Addressed

Children covered by Medicaid (who represent roughly two-thirds of the Medicaid population) face an increased risk of developmental delays, behavioral disabilities, and associated problems later in life. Early identification and intervention—ideally before age 3 years—offer the best chance for these children to become ready for school and achieve maximum emotional and intellectual development. Yet few children with such delays are identified and receive treatment in a timely manner. Although patient-centered medical homes (PCMHs) have the potential to better serve this population, current guidelines and certification programs focus on medical management, and hence PCMHs may not live up to this potential.1,2
  • Increased risk of developmental and behavioral disabilities: Nationwide, approximately 14 percent of children have a developmental or behavioral disability, including autism, attention deficit hyperactivity disorder, hearing loss, learning disabilities, stuttering, seizures, or cerebral palsy. The risk tends to be much greater among children covered by Medicaid and the Children's Health Insurance Program (more than 20 percent) than those covered by private insurance (12 percent). Children who have developmental disabilities have higher health care costs, greater need for special education, and lower income-earning potential than children without these conditions. 1,2
  • Unrealized potential of early detection and intervention: A child's failure to meet key developmental milestones during the first 3 years of life often indicates the presence of a developmental or behavioral disability. Early identification and intervention in these cases—including evaluation and appropriate use of speech and language or occupational therapy—can reduce the need for special education, improve school performance (including the likelihood of graduating high school), and reduce the risk of teen pregnancy.2 The American Academy of Pediatrics recommends that clinicians administer developmental screening tests at regular well-child visits,2 yet in 2007 only 20 percent of children received such screening across the nation and less than 14 percent received it in Oregon.3 Only approximately 2 percent of children across the nation receive early intervention services.
  • Missed opportunity, even for PCMHs: The PCMH model seemingly has the potential to serve children with developmental disabilities well, given its emphasis on disease management and coordination of care across providers, particularly for chronic conditions. Yet PCMH certification guidelines, requirements, and policies generally do not take into account children’s special developmental needs, which often are most easily addressed by schools and community organizations that have not traditionally been part of the care coordination team. In addition, PCMH-related reimbursement policies may not explicitly encourage clinicians to perform routine developmental screenings, which leads to missed diagnoses and poorly coordinated care.4

What They Did

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Description of the Innovative Activity

The Oregon Health Authority implemented a series of policy changes to emphasize and promote earlier detection, more effective referrals, and better coordination of care for pediatric patients with developmental delays. Key changes include encouraging contracted plans to participate in projects to improve screening rates, modifying State standards for PCMHs to emphasize the special developmental needs of children, and instituting a data-sharing agreement to formalize and strengthen care coordination and improve performance tracking. Key elements of these policy changes are detailed below:
  • Encouraging participation in improvement project focused on screening: Before implementation of these policy changes, Oregon Health Authority already required managed care organizations to pursue two performance improvement projects each year. To encourage providers to choose one project focused on screening children for developmental delays, the Oregon Health Authority laid the groundwork for development of a statewide collaborative, as outlined below:
    • Community engagement: In 2008 and 2009, Oregon Health Authority held a series of town-hall style and other community meetings that brought together parents, pediatric primary care and other providers, and representatives of agencies focused on early intervention. Participants shared their perspectives on how to eliminate barriers to care, improve communication among stakeholders, and coordinate care more effectively. In 2010, the Oregon Health Policy Board convened the Patient Centered Primary Care Home Pediatric Standards Advisory Committee that included providers, patient advocates, and educational and social services experts. (The Context section provides more information on the Oregon Health Policy Board.) Although the committee no longer exists, a Joint Policy Advisory Group (with representation by health and education professionals) was formed to provide input on some of the more complex systems level issues.
    • Technical assistance: Oregon Health Authority worked with managed care organizations and the State pediatric society to offer training, technical assistance, and other resources to support plans and their network providers in becoming part of a performance improvement project focused on screening for developmental delays. This cooperation eventually led to the establishment of a statewide initiative known as the Oregon Pediatric Improvement Partnership.
  • Modification of PCMH standards and policies: Children with developmental needs require services from various settings outside of health care, including schools, early intervention agencies, and other community-based providers. However, existing certification programs for PCMHs did not require health care providers to include these other settings in their care coordination efforts. To address this problem, Oregon Health Authority made a series of changes to PCMH standards to reflect the importance of monitoring developmental milestones in young children and to support parents, other family members, and community-based organizations that serve young children in encouraging healthy development and addressing any delays or conditions in a timely manner. Key changes are outlined below:
    • Official adoption of guidelines: The American Academy of Pediatrics Bright Futures guidelines for pediatric primary care providers were adopted as part of the PCMH standards. These guidelines recommend developmental screenings for children at the 9-month, 18-month, and 30-month well-child visits.
    • Revised certification requirements: To attain certification as a PCMH, primary care providers now must have a documented screening strategy for developmental conditions and maintain referral sources for children who screen positive. In addition, to attain the highest level of certification, providers must track referrals and, as appropriate, coordinate care rendered in settings outside the medical home, including dental services, education, social services, foster agency services, and care provided by public health or long-term care facilities. They must also track relevant outcomes measures, such as developmental milestones and readiness to read by kindergarten.
    • Incorporation of measures into required shared care plan: The Oregon Health Authority adjusted the goals and policies related to the development of shared care plans for pediatric patients in PCMHs to incorporate a set of outcome measures related to early detection and intervention for those with developmental delays. Examples include measures to gauge whether children are: achieving developmental milestones, ready to read when they enter kindergarten, and receiving timely immunizations and preventive services.
    • Formal recognition of family role: Providers seeking designation as a PCMH must assess family satisfaction and document family education activities.
    • Special payment code to prioritize developmental screening: Oregon Health Authority brought more attention to the need for developmental screening by creating a specific payment code for them, rather than including payment as part of the standard fee for well-child visits. Overall payments to PCMHs did not necessarily increase as a result of this change (because payment for the general visit fell). Rather, the goal was to create a separate payment so as to encourage clinicians to perform the screenings.
    • Reimbursement for case management, care coordination: The Authority changed policies to allow for reimbursement for multidisciplinary care coordination conferences by qualified nonphysicians and for case management performed by community-based agencies focused on early intervention. Specifically, the Prioritized List of Health Services, which ranks cost-effective treatment for certain conditions and is a cornerstone of the Oregon Health Plan, now includes interdisciplinary team consultation for developmental disability, setting the stage for reimbursement for that service.
  • Data-sharing agreement between Medicaid providers and early intervention agencies: Oregon established a data-sharing agreement between Medicaid providers and community-based agencies providing early intervention services. The goal was to formalize and improve referral processes, increase communication across providers and between providers and agencies, and support the aforementioned performance improvement project. Before these changes, providers would refer patients to early intervention by giving parents a list of agencies offering such services and leaving it up to them to make an appointment. To improve that approach, the data-sharing agreement includes the following:
    • Standard referral form for parent and agency: Primary care providers now refer patients to early intervention services by using a standard form that can be transmitted by paper, fax, or electronically, in accordance with Federal privacy guidelines. The form goes to parents and the agency, thus establishing a mechanism for the agency or provider to follow up if the parent does not make an appointment.
    • Additional fields for provider information and communication preferences: Previously, the early intervention referral form did not include a place to list the child’s primary care provider. Consequently, these providers often did not receive reports from the agencies on the child's evaluations and progress. To address this issue, fields were added to allow the primary care provider to list his or her contact information and indicate what types of information he/she would like to receive. As a result, early intervention agencies can now keep the provider in the loop, either by sending a notice when new results are available or delivering those results automatically. This change also allows the provider to follow up with families to ensure they make and keep appointments, and to contact any agency that does not provide the requested information in a timely manner.
    • Shared claims data: The agreement allows Medicaid to share individual and aggregate claims data with providers related to early intervention and other services received outside of the plan network. This information enables providers to monitor and follow up on care provided by community-based agencies, and facilitates inclusion of these other service providers on the care coordination team. It also helps the state assess progress in reaching performance improvement goals related to identifying and treating children with developmental delays.

Context of the Innovation

In 2009, the Oregon legislature created the Oregon Health Authority to lead the state’s ongoing efforts to improve the health of residents; increase the quality, reliability, and availability of health care; and reduce or contain the costs of care. A board consisting of nine citizens oversees the Authority, which receives Federal and State funds to administer the Oregon Health Plan, Community Mental Health, and Healthy Kids programs that serve Medicaid-eligible Oregonians, State employees, and local school district employees.

The impetus for this program began in 2009, when Oregon applied to participate in the third iteration of the Assuring Better Child Health and Development Program (ABCD III), funded by the Commonwealth Fund and administered by the National Academy for State Health Policy. The purpose of the grant initiative was to develop and test models to improve care coordination for children with or at risk of developmental delays.

Did It Work?

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Results

Collectively, the policy changes have encouraged many managed care organizations to focus on this issue, significantly increased screening rates, and enhanced access to early intervention services.
  • High participation among managed care organizations: Program developers expected 3 of the state’s 12 managed care organizations to participate in the aforementioned statewide quality improvement project focused on screening. However, 8 signed up, representing approximately 80 percent of children enrolled in Oregon’s Medicaid program and approximately one-fifth of the state’s total pediatric population.
  • Doubling of screening rates: In 2007 (before the policy changes had been developed and implemented), less than 14 percent of children in the state received developmental screenings, well below the national average of 20 percent. By 2012, the screening rate had more than doubled to 30 percent, and Oregon ranked twelfth in the nation on this measure.
  • Better access to early intervention services: The data-sharing agreement and other policies have improved communication between health care providers and early intervention agencies, which in turn has enhanced access to care by allowing barriers to be addressed, including transportation issues, scheduling problems, and other difficulties. For example, before adoption of these changes, many parents and providers did not realize that Medicaid will assist with transportation. Once early intervention services became part of the overall care plan for the child, it became clearer to providers and parents that such assistance was available, and hence it became easier for parents to get their children to appointments.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of screening rates for developmental delays, along with post-implementation data on the number of managed care organizations participating in a quality improvement project and anecdotal reports from providers and parents about the program's impact on access to early intervention services.

How They Did It

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Planning and Development Process

The program evolved over time, with key milestones listed below:
  • Participation in collaborative focused on screening: In 2007, Oregon was 1 of 21 states to participate in the ABCD Screening Academy, which brought together primary care, early intervention, and public health authorities to increase use of developmental screening tools as part of well-child care. This program preceded the ABCD III grant initiative.
  • Statewide effort to integrate mental and physical health services: In 2009, Oregon began a series of demonstration projects to better integrate mental and physical health services, with the goal of improving quality, coordination, and access for both types of care.
  • Formation of authority to coordinate regulations and policies: Also in 2009, the Oregon legislature passed legislation that created the Oregon Health Policy Board and the Oregon Health Authority, with the goal of bringing together the state’s patchwork system of regulations, policies, and procedures into a coordinated system that encouraged innovations to improve the quality of care and the health of the population while simultaneously reducing costs. This same legislation established the Patient-Centered Primary Care Home Program to promote the medical home model in the state.
  • Recognition that children need a different model to coordinate care: These simultaneous efforts brought forward the realization that the standard PCMH model did not take into consideration the developmental needs of children, and that changes had to be made to certification and other requirements for PCMHs to ensure better care for children with developmental disabilities.

Resources Used and Skills Needed

  • Staff: Four staff members worked on the project over a period of 4 years, including a senior policy adviser, the medical director of the Oregon Pediatric Improvement Partnership, and two individuals who organized the community meetings.
  • Costs: The program had an annual budget of $240,000, which covered staff salaries, training, town hall and other community meetings, data analysis, and support for the performance improvement partnership.
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Funding Sources

Centers for Medicare and Medicaid Services; Commonwealth Fund; Oregon Health Authority
The Commonwealth Fund contributed $60,000 a year for 4 years. Because Oregon used the funds to implement a performance improvement plan, CMS provided $2 in matching funds for each $1 contributed. The Oregon Health Authority contributed to the program by paying the salaries and benefits of employees who spent time on this project.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Leverage available funding sources: By using the ABCD III grant money to design and implement a performance improvement project, Oregon Health Authority turned $60,000 a year into $240,000 a year, which made possible a much larger program that had a greater impact on quality of care.
  • Get input from all stakeholders early in process: The town hall and other community meetings helped to secure buy-in and elicit input from mental health and pediatric providers, early intervention specialists, and families of children with developmental disabilities. Developers of the Oregon program especially appreciated the candid responses of parents who felt overwhelmed in managing and sorting through the (often conflicting) information provided by various service providers. Hearing their experiences and ideas helped policymakers develop new standards and procedures to ensure better care coordination across disciplines.

Sustaining This Innovation

  • Tweak payment policies without raising overall costs: Instead of adding reimbursement for developmental screening, the Oregon Health plan separated the screening reimbursement from the fee paid for the rest of the well-child visit, thus creating an incentive for screening without raising the overall cost of the well-child visit.
  • Offer providers options for what information they receive: In the initial days of the data-sharing agreement, some early intervention agencies sent full reports and lengthy family service plans to providers, often giving them more information than they wanted or could possibly use. To prevent this problem, the referral form was changed to let providers indicate the specific information they wanted (i.e., evaluation reports, eligibility statements, or individual family service plans).
  • Once implemented, shift responsibility to managed care organizations: Once information systems had been set up and policy changes made, the Oregon Health Authority shifted responsibility to the managed care organizations for publicizing the availability of services to parents (via brochures and their Web sites) and for helping network providers understand the various provisions of the policy changes.

More Information

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Contact the Innovator

Charles A. Gallia, PhD
Senior Policy Advisor
Oregon Health Authority
421 SW Oak
Portland, OR 97204
(503) 884-2458
E-mail: Charles.a.Gallia@state.or.us

Innovator Disclosures

Dr. Gallia reported that his employment is supported by Oregon Health Authority and the Oregon Health Plan. He also reported receiving payments for expert testimony from the Centers for Medicare & Medicaid Services (CMS) and reimbursement of travel expenses from the Agency for Healthcare Research and Quality, both for activities relevant to the work described in this profile. In addition, his employer (Oregon Health Authority) has received grants from CMS related to this work.

References/Related Articles

Henderson M, Kaye N. Policies for care coordination across systems: lessons from ABCD III. National Academy for State Health Policy. 2012 May. Available at: http://www.nashp.org/sites/default/files/ABCDIII.policies.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Footnotes

1 Boyle CA, Boulet S, Schieve LA, et al. Trends in the prevalence of developmental disabilities in US children, 1997-2008. Pediatrics. 2011;127(6):1034-42. [PubMed]
2 Sices L. Developmental screening in primary care: the effectiveness of current practice and recommendations for improvement. The Commonwealth Fund. 2007 Dec. Available at: http://www.commonwealthfund.org/Publications/Fund-Reports/2007/Dec
/Developmental-Screening-in-Primary-Care--The-Effectiveness-of-Current-Practice-and-Recommendations-f.aspx
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3 National Survey of Children's Health. NSCH 2007. Child and Adolescent Health Measurement Initiative, Data Resource Center for Child & Adolescent Health. Available at: http://www.childhealthdata.org/browse/survey/results?q=867&r2=39.
4 Hanlon C. Supporting healthy child development through medical homes: strategies from ABCD III states. Briefing: A Publication of the National Academy for State Health Policy. 2012 Nov. Available at: http://www.nashp.org/sites/default/files/child.development.medical.home_.abcd_.III_.pdf.
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Original publication: September 11, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: September 11, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.