North Carolina program improves well-child screenings

Changing doctor office processes as part of the North Carolina Assuring Better Child Health and Development (ABCD) Project has resulted in a significant increase in screening rates to more than 70% of the designated well-child visits. Data from the project prompted a change in Medicaid policy and screening now are statewide in primary practices that perform Early Periodic Screening, Diagnosis, and Treatment (EPSDT) examinations.

Dr. Marian Earls, of Guilford Child Health, Greensboro, NC, and the University of North Carolina School of Medicine Department of Pediatrics, says while some features of the program are specific to North Carolina, there are elements that could be used by any practice or state interested in integrating child development services into the medical home.

Dr. Earls tells State Health Watch the initial work was done under a Commonwealth Fund grant for a quality improvement project in one county that then took off.

Developmental screening and surveillance are recommended at well-child physicians visits, according to Ms. Earls, as a key component of preventive care for children. With primary care providers the best-informed professionals with whom families have regular contact over a child's first five years of life, screening is important as a way to facilitate early identification and referral for infants and children who need early intervention services.

The problem, Dr. Earls says, is that only 30% of children needing services are identified by school age because too often primary care physicians don't identify their needs in the course of well-child care, demonstrating the need for systems to integrate the use of formal, validated screening tools.

And the benefits of screening and surveillance aren't limited to children with developmental and behavioral delays. For typically developing children, families still benefit by increased awareness of appropriate developmental and behavioral expectations.

The ABCD project was started in North Carolina in August 2000 to pilot test formal developmental screening and surveillance for children receiving EPSDT services in pediatric and family practices. The project's goals were to assist physician practices in implementing an office process for screening that would be efficient and practical, to promote early identification and referral, and to facilitate practice ability to link to early intervention and other community services. The intent was to establish a sustainable system for the entire state. The project started in one county, was replicated to nine additional counties, and then became a statewide Medicaid policy in 2004.

IDing those at risk

The model built on Community Care of North Carolina, the state's physician-driven enhanced primary care case management program. The community networks are designed to better manage services for the Medicaid population. Many of them also have expanded services to other populations such as those in the SCHIP program and the uninsured.

Dr. Earls says the heart of the program is community providers taking a population-based approach to managing enrollee care by systematically identifying patients at risk and then bringing in the processes and supports needed to manage the care.

A key project characteristic, Dr. Earls reports, is that it is physician-/ practice-driven. The process began with physicians exploring options for a screening process that would be compatible with a busy office schedule, be satisfying to parents, optimize early identification of infants and toddlers who are at risk, and facilitate anticipatory guidance in promoting successful developmental outcomes.

In choosing a screening tool, factors that were considered included the type of screen, staff required, time required, and cost. Parent-completed tools required little staff time, were not costly, and fit well into the office flow. Also, they engaged the parents as experts of their own children and acknowledged the partnership between parents and providers in caring for children.

Dr. Earls says based on the experience of the initial pilot and other practices that later joined the project, key steps identified for the office process include:

  • assessing current office protocols;
  • identifying a physician champion to maintain the initiative as a priority;
  • selecting a screening tool;
  • mapping the workflow;
  • identifying system supports to facilitate networking with community partners;
  • conducting staff orientations, being sure to include nursing and office staff who will be instrumental in the office flow;
  • sharing process and outcome data at regular intervals with staff.

Expanding the program

Information that has been shared with other states that have inquired about following North Carolina's lead include the need to identify a physician champion to lead project activity, directing activity from a local level rather than at the state level, piloting activity before trying to replicate it, replicating activities after data are collected and shared, developing policies for best practices in well-child care on the basis of local activity experience, aligning goals with collaborating partners to help ensure active participation from partners, and identifying care management resources in local communities to support the practice and family rather than hiring additional staff.

Dr. Earls tells SHW it's important to recognize that doctors typically are not the people who best know how a practice is run, and it's important to work with the office staff on practical issues, such as who hands out the parent-screening tools and who puts them in the patient charts.

Physicians have positively reacted to the program, she says, because using the screening tool makes well-child visits more efficient and the responses from parents can be used to provide guidance to them. And, she says, parents understand their own child's development better than the professionals do and love being asked to talk about it. Because of the screening tool, she says, doctors and parents can spend time talking about those things the parents are actually concerned about.

A key to project success outside of the well-child visits, Dr. Earls says, is for physician practices to make full use of other community services and resources that are available.

"We encourage practices to network, to go out and talk with people and not just build phone lists," she explains. "It's been hugely effective in forging relationships that become very helpful to families who need something. It can be particularly useful if there are already truly collaborative activities under way."

Commonwealth Fund is continuing to promote project spread, Dr. Earls says, recognizing there will be variations from state to state. She says an important key to long-term success in North Carolina was that the project started with physicians, meaning there was more doctor buy-in that if it had been mandated by Medicaid.

"You need a physician champion," Dr. Earls says, "someone who can go to new practices and tell them of people they know who are already participating."

To help promote the program, ABCD has produced a training DVD for physician practices that includes interviews with doctors who have been participating in the effort.

Download Dr. Earls' report on the project from the journal Pediatrics at Contact her at (336) 272-1050, ext. 2231, or e-mail: