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Pathways from Screening to Services – Northwest OR

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Led by the Northwest Early Learning Hub (NWELH) and funded by Columbia Pacific Coordinated Care Organization, this two-year project aims to improve the receipt of services for young children who are identified at-risk for developmental and behavioral delays. 

The project supports:

  1. Cross-sector stakeholder engagement and baseline data collection about current processes and where children are lost to follow-up;
  2. The development, implementation, and evaluation of improved follow-up processes, including referral to and coordination of services that help at-risk young children to be ready for kindergarten. 

The Oregon Pediatric Improvement Partnership (OPIP) is a critical partner, supporting the development of stakeholder engagement and evaluation methods and the transformation activities within primary care clinics meant to enhance follow-up and care coordination for children identified at–risk. The project builds off previous efforts OPIP has led in other communities. 

Stakeholder Engagement

Through stakeholder interviews and county-level meetings, we used a collective impact model to engage stakeholders within health care, Early Intervention (EI), and early learning focused on developmental screening and/or who provide follow-up services for children identified at-risk for delays on developmental screening tools. Baseline qualitative and quantitative data have been collected in order to: 

1) Understand the current pathways from developmental screening to services in Clatsop, Columbia, and Tillamook, and the community-level assets and resources that exist to support follow-up services; and 

2) Understand where and how children are falling out of these pathways and not receiving services to address the identified risks, including where there is a lack of capacity to serve children identified. 

Stakeholder Meetings

Tri-County

Columbia

Clatsop

Tillamook

Asset Mapping & Triage and Referral Map

Informed by presentation of the baseline data and community-level asset maps the communities have identified the priority areas for follow-up and early learning resources where improvements will be focused. To support the improved processes, community-specific triage and referral processes are being developed to match the at-risk child and family with the most appropriate follow-up providers based on the child’s developmental screening risk scores and other child/family factors. 

The referral pathways are within health care, EI, mental health, and other priority early learning providers identified at the community-level meetings. A component of the pathways developed will be secondary referral and support strategies for children found ineligible for the initial referred services. Referral processes will include feedback loops to support communication and coordination. 

Piloting Improvements

The sites that will pilot the improved processes are: 

  1. Four primary care practices serving a large number of publicly insured children residing in these counties: OHSU Family Medicine at Scappoose, Columbia Memorial Health Pediatrics, Tillamook County Community Health Center, and Adventist Women and Families Clinic in Tillamook
  2. Early Intervention – Northwest Regional Early Service District Service Centers in Columbia, Clatsop and Tillamook Counties.
  3. Mental Health Providers – Clatsop Behavioral Health and Columbia Community Mental Health

Implementation in the sites will be staggered over the two-year project. Sites will receive improvement and transformation tools developed by OPIP, monthly implementation support, and refinements to the improvement tools will be made based on lessons learned and barriers identified. 

Spreading Innovation & Sharing Lessons Learned 

At the end of the project a number of generalizable tools will be developed to support the spread of innovation more fully across all three counties in the CPCCO region including the following: 

  1. A toolkit for primary care practices;
  2. EI referral and care coordination methods;
  3. Family resource management and care coordination tools for early learning providers. 

As the backbone organization of early learning across all three counties, NWELH will also convene all county-level stakeholders together semi-annually to share the learnings, discuss implications for spread, and to inform priorities for the NWELH.