Consulting to Yamhill Coordination Care Organization and Yamhill Early Learning Hub on Follow-Up to Developmental Screening
The Oregon Department of Education’s (ODE) early learning system and the Oregon Health Authority share a common focus on community and population based developmental screening. Specifically, within the Early Learning Hub (ELH) and Coordinated Care Organizations (CCO) there are priorities and related metrics that focus on the number of children screened. The goal of developmental screening is that children identified “at-risk” for developmental, behavioral, and social delays be referred to and receive services addressing those delays. This pathway, from developmental screening to receipt of services, supports early and timely provision of services meant to ensure that children are ready for kindergarten. ELH responsibilities related to family resource management, coordination of services, and ensuring children are kindergarten-ready are aligned with the broader goals around ensuring follow-up services.
To address these synergistic goals between the ELH and CCO, the Oregon Health Authority’s Maternal & Child Health section supported OPIP to provide consulting to Yamhill Coordinated Care Organization and Yamhill Early Learning Hub on follow-up to developmental screening. The project was supported by Funding Opportunity Number CMS-1G1-12-001 from the U.S Department of Health and Human Services, Centers for Medicare & Medicaid Services. That said, the content described on this page and disseminated through the project is solely the responsibility of OPIP does not necessarily represent the official views of HHS or any of its agencies.
Overview of the Project:
- Two-Page Overview of the Project in Yamhill County
- Overview presentation of key activities and learnings from the project
- Final Project Summary
Please click the following links to move to the appropriate section below:
1) Engage and facilitate key stakeholders
2) Triage and referral system map
*Please Note: The project was supported by Funding Opportunity Number CMS-1G1-12-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. That said, the content described on this page and disseminated through the project is solely the responsibility of OPIP does not necessarily represent the official views of HHS or any of its agencies.
1) Engage and facilitate key stakeholders* in Yamhill County on the shared goal of ensuring children identified at-risk receive services:
Obtaining community input, buy-in, and ensuring the project was tailored to Yamhill County is a critical component of this project. OPIP conducted stakeholder interviews across the county who are either doing developmental screening or who can provide follow-up services to children identified at risk. OPIP also collected data about screening and follow-up from Yamhill Coordinated Care Organization (YCCO) and Early Intervention-Willamette Education Service District (WESD). Lastly, OPIP hired parents of young children to serve as advisors to the project. Parent engagement is an important component to all quality improvement activities at OPIP. Two parent advisors were recruited to provide insight and share their experiences to help identify key issues or barriers within the referral and triage process, as well as gather feedback about educational materials and resources to ensure they are patient-centered.
Periodically these stakeholders met to review the key findings, identify project priorities and learnings, and to ensure that the findings were used to inform system-level improvements.
Stakeholder Meetings:
– January 2016 Meeting
– March 2016
– August 2016
– December 2016
*Please Note: The project was supported by Funding Opportunity Number CMS-1G1-12-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. That said, the content described on this page and disseminated through the project is solely the responsibility of OPIP does not necessarily represent the official views of HHS or any of its agencies.
2) Triage and referral system map* to identify the best set of services for children who are identified at-risk (using the ASQ) tailored to Yamhill County:
A key component of this process was to summarize the findings from the stakeholder interviews to describe the current developmental screening pathways, conduct asset mapping of resources in the community to address the risks identified, and then to identity the community priorities for where to focus improvement efforts. Below is a link to a summary referral and triage map noting the opportunity and pathways for follow-up to developmental screening in Yamhill County.
- Yamhill County Pathways from Screening to Services – Referral and Triage Map
- Pathways from Screening to Services – Generic asset mapping template that can be used within your own community
Stakeholders in Yamhill County identified the following as priorities for their improvement efforts:
- Enhanced referrals and parent supports within Primary Care
- Childcare providers conducting developmental screening – Parent education for childcare providers to encourage connection to PCPs for children identified at-risk
- Enhanced communication and coordination between Primary Care and Early Intervention
- Enhanced referrals from primary care to home visiting
- Enhanced referrals from Early Intervention to home visiting
*Please Note: The project was supported by Funding Opportunity Number CMS-1G1-12-001 from the U.S Department of Health and Human Services, Centers for Medicare & Medicaid Services. That said, the content described on this page and disseminated through the project is solely the responsibility of OPIP does not necessarily represent the official views of HHS or any of its agencies.
3) Methods and processes* for how care can be coordinated at a child-level, across primary care and community-based providers.
The stakeholders in Yamhill County identified the following as priorities for their improvement efforts:
- Enhanced referrals and parent supports within Primary Care
- Childcare providers conducting developmental screening – Parent education for childcare providers to encourage connection to PCPs for children identified at-risk
- Enhanced communication and coordination between Primary Care and Early Intervention
- Enhanced referrals from primary care to home visiting
- Enhanced referrals from Early Intervention to home visiting
To support these efforts, OPIP helped to identify and, if models were not developed, to create new tools to address the priority areas identified:
a) Enhanced referrals and parent supports within Primary Care:
- Primary Care medical decision tree to inform follow-up to developmental screening
- Training on referral to EI and other community resources
- Decision support of when to refer to EI and/or home visiting in Yamhill County, based on the child’s ASQ score
- Supporting decision support in the EMR
- Better supports to families of children identified at-risk and referred to services:
– 36-hour phone follow-up script for staff to use with families who are referred to services to answer questions and address barriers and reduce the number of children not able to be evaluated.
b) Childcare providers conducting developmental screening – Parent education for childcare providers to encourage connection to PCPs for children identified at-risk:
- Some childcare providers are not doing developmental screening. Click here to see a one-page education sheet created for child care providers to give to parents of children identified at-risk to share key next steps.
c) Enhanced communication and coordination between Primary Care and Early Intervention:
- Training on the use of the EI Universal Referral Form
- Click here to see a draft of pilot communication methods with EI that include communication when EI is unable to evaluate the child, results of the evaluation, and a summary of services being received to inform secondary referral and follow-up.
d) Enhanced referrals from primary care to home visiting:
- A summary of methods to refer to home visiting proposed in Yamhill can be found by clicking here.
*Please Note: The project was supported by Funding Opportunity Number CMS-1G1-12-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. That said, the content described on this page and disseminated through the project is solely the responsibility of OPIP does not necessarily represent the official views of HHS or any of its agencies.
