Developmental Surveillance and Screening Policy Implementation Project (D-PIP)

 D-PIP Study Publication
“Implementing Developmental Screening and Referrals: Lessons Learned From a National Project” was early released on January 25, 2010 via Pediatrics eFirst Pages: www.pediatrics.org or http://pediatrics.aappublications.org/cgi/reprint/peds.2009-0388v1 (direct link - subscription to Pediatrics required). The study will also appear in the February print edition of Pediatrics.

In 2006, the AAP released a policy statement on developmental surveillance and screening, including an algorithm to aid practices in implementation. Simultaneously, the AAP launched a 9 month pilot project, the Developmental Surveillance and Screening Policy Implementation Project, in which 17 diverse pediatric practices sought to implement the policy statement’s recommendations. The project assessed the degree to which a national sample of practices could implement recommendations for developmental screening and referrals, and identified factors contributing to the successes and shortcomings of these efforts.

At the project’s conclusion, practices reported consistently screening more than 85% of patients at recommended ages. They achieved this by dividing responsibilities among staff and actively monitoring and measuring implementation. Challenges were identified in implementing a 30 month visit; administering a screen after surveillance suggested concern, and submitting simultaneous referrals both to medical subspecialists and local early intervention programs. Practices reported referring only 61% of children with failed screens. Many practices also struggled to track referrals.

Overall, the project uncovered that a diverse sample of practices successfully implemented developmental screening as recommended by the AAP. Practices were less successful in placing referrals and tracking those referrals. More attention needs to be paid to the referral process, and many practices may require separate implementation systems for screening and referrals.

Project Purpose | Practice Teams | Research Methods | Resources for Practices | Q&A

This project examined the following questions:

1. Can the algorithm be efficiently and effectively implemented into pediatric practice
2. What strategies are used by practices to successfully implement the algorithm (eg, office procedures, time accommodations, follow-up procedures)?
3. What are the outcomes of implementing the algorithm?

Practice Teams
17 practices were selected to participate in the D-PIP. Click here to view the list of practice teams who participated in the project.

Practice teams were responsible for:

• Identifying 3 practice team members, one of which must be a pediatrician who will serve as the team leader for this project (Note: completed)
• Choosing a well-defined method of data collection for the practice (eg, chart review, tally-method, administrative systems reporting/EMR, etc) and identifying a practice team member to lead the data collection efforts (Note: completed)
• Participating on a conference call to discuss baseline data collection and reporting (Note: completed)
• Collecting and reporting on baseline data for 1 month using a standard data reporting form (Note: completed)
• Completing a pre-implementation survey (Note: completed)
• Sending the entire practice team to a training/planning workshop (Note: completed)
• Preparing the practice for implementation for 2 weeks following the workshop (Note: completed)
• Implementing an algorithm using strategies determined by the practice team
• Collecting and reporting on data monthly for 9 months following the training using a standard data reporting form
• Maintaining a list of children age 8-36 months who were referred for questions addressed in the post-implementation survey
• Completing a post-implementation survey
• Sharing data and reports with AAP project staff and principal investigator
• If owned by a health care institution, seeking Institutional Review Board approval for participation in the project

Research Methods
The overall design of the project included:

1. A pre-implementation survey conducted upon practice selection
2. A baseline assessment for 1 month
3. A training/planning workshop / implementation resources
4. A data collection period for 9 months
5. A post-implementation survey
6. Qualitative Interviews

Pre-Implementation Survey
The pre-implementation survey was the method used to determine the practices’ understanding of developmental surveillance and screening, as well as their current procedures regarding developmental surveillance, screening, and referral.

Baseline Assessment
A baseline assessment was conducted for 1 month prior to a training workshop. Practices were required to report data using a standard reporting form that reflected the type of data each practice needed to collect. The method of data collection was the individual choice of the practice.

Training/Planning Workshop Photo
A training/planning workshop was conducted for the 17 practice teams in June 2006 to introduce them to the new policy recommendations and algorithm and help them develop a plan for implementation.

Learning objectives included:

1. Establish a clear understanding of the policy implementation project and practice responsibilities
2. Demonstrate a working knowledge of the algorithm and policy statement
3. Provide sample data collection methods and strategies and explain the data reporting tool instructions
4. Develop skills in using appropriate CPT codes for developmental surveillance and screening (96110)
5. Understand confidentiality requirements of the project
6. Identify and outline steps for implementing the policy statement and algorithm into their particular practice

Power Point Presentations

• The Developmental Surveillance and Screening Policy Implementation Project; Paul Lipkin, MD, FAAP Presentation
• Office Systems Change; Paula Duncan, MD, FAAP: Presentation
• Developmental Surveillance and Screening; Paul Lipkin, MD, FAAP Presentation
• Introduction to Policy Statement Algorithm; Nancy Swigonski, MD, MPH, FAAP: Presentation
  
• Developmental Screening Tools; Michelle Macias, MD, FAAP Presentation
• Putting the Office Systems in Place/Overview of Data Collection; Paula Duncan, MD, FAAP: Presentation
• Developmental Screening: Billing and Coding; Michelle Macias, MD, FAAP Presentation
  Sample appeals letter to insurers advocating separate payment for developmental screening Handout
  
• Screening Implementation: Referral and Follow-up; Paul Lipkin, MD, FAAP Presentation

Resources to Help the Practice Change Process

• Improvement Checklist: Steps to Using Screening and Surveillance in Your Office
• Integrating Developmental Screening Worksheet
• Developmental Screening Tools Grid
  (Description | Age Range | No. of Items | Administration Time | Psychometric Properties | Scoring Method | Cultural Considerations | Purchase/Obtainment Information | Key References)

Resources to Implement Practice Changes

• Community Resource Template
• Chart Labels
• Early Intervention Referral Form
• Referral Tracking Worksheet

Monthly Data Collection
Practices collected data reflecting the algorithm for 9 months.

• Monthly Data Reporting Form (July and March)
• Monthly Data Reporting Form (August through February)
• Data Collection Strategies

Post Implementation Survey
A Post-Implementation Survey was conducted to determine:

1. If changes were made in the knowledge and delivery of developmental surveillance and screening as a result of the policy statement implementation
2. Strategies used to implement the policy statement/algorithm
3. Outcomes of implementation, benefits of the algorithm process, and barriers encountered
4. Overall evaluation – based on this experience, will your practice continue to do this?

Qualitative Interviews

The Commonwealth Fund funded an expansion of the D-PIP that included qualitative interviews conducted by evaluators from Johns Hopkins University. The evaluators conducted 2 rounds of telephone interviews asking 3 practice team members in each practice about such issues as families' response to screening implementation, the amount of staff effort, time and money required to implement, helpful resources, and disruption to usual patient flow.

Question and Answer (Q&A)

Additional resources and tools are available by clicking here.

For additional information on the D-PIP, please contact Holly Griffin, Manager, Medical Home Surveillance and Screening at 800/433-9016, ext 7863 or hgriffin@aap.org

The D-PIP was funded by a cooperative agreement between the AAP and the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention, a cooperative agreement between the AAP and the Maternal and Child Health Bureau, and additional funding from the Commonwealth Fund.

Updated: January 25, 2010