Care Coordination and Linkages to Services

As providers conduct more screening and identify more children in need of follow-up services, the weakness of the U.S. child-serving systems and inadequacy of linkages among providers becomes increasingly apparent.* It is clear that more must be done to improve referrals and assure access to services essential as follow up to screening. Promising approaches for improving follow up and strengthening linkages are underway at the practice, community, and state levels. Many such projects and initiatives aim to help families benefit from screening and surveillance in pediatric primary care by connecting them and their children to services and supports they needs.
ABCD states found that improving linkages between primary care providers and other child and family and service providers is critical to promoting healthy development for children. The ABCD III initiative is focusing attention on models that will improve linkages to promote child development as the result of screenings. The collaborative will help state agencies, especially Medicaid agencies, in developing more effective referral pathways between pediatric primary care practices and community intervention and support agencies to promote the healthy development of young children.
Building on previous ABCD efforts, these projects will seek to identify existing assessment and treatment resources, remove policy barriers to accessing those services, and facilitate referrals to these resources. States play an important role in removing barriers and providing support as communities move toward more integrated services. This section focuses on resources designed to assist states working to address the health and developmental needs of children and families. _______________________________________________________________________________________________________________________________
*Johnson K and Rosenthal J, Improving Care Coordination, Case Management, and Linkages to Service for Young Children: Opportunities for States. (Portland, ME: The National Academy for State Health Policy, April 2009).

 

Title Description Date Published Resource State
Early Interventioners Assemble! Implementing Developmental-Behavioral Screening Tools in Primary Care (Dr. Kevin Marks, MD, FAAP: 2013) This “nuts and bolts” presentation can be used to help implement developmental-behavioral screening tools in combination with evidence-based developmental-behavioral promotion into pediatric office settings. The presentation also discusses the importance of care coordination. June 2013 State-specific Oregon
Early Intervention and Early Childhood Special Education Spanish Language Brochure (Oregon ABCD III Project: 2013) This is a Spanish translation of the below brochure. April 2013 State-specific Oregon
Early Intervention and Early Childhood Special Education Brochure (Oregon ABCD III Project: 2013) This brochure was designed by the Oregon ABCD III team to provide information on the state’s Early Intervention and Early Childhood Special Education Program. The brochure includes information on the services offered, who can refer a child to the program, as well as contact information. April 2013 State-specific Oregon
Early Intervention/Early Childhood Special Education (EI/ECSE) Spanish Language Referral Form for Providers Birth to Age 5 (Oregon ABCD III Project: 2012) This is a Spanish translation of the below form. April 2013 State-specific Oregon
Early Intervention/Early Childhood Special Education (EI/ECSE) Referral Form for Providers Birth to Age 5 (Oregon ABCD III Project: 2012) This form was developed by the Oregon ABCD III team for providers to refer children to either Early Intervention or Early Childhood Special Education. The form is HIPAA and FERPA compliant and contains contact information for Oregon EI/ECSE offices. April 2013 State-specific Oregon
Infant & Toddler Connection of Virginia Referral Form (Infant & Toddler Connection of Virginia) This is the standard referral form that was developed by Virginia in conjunction with the state’s ABCD Screening Project. The form is both HIPAA and FERPA compliant to allow for the sharing of information. January 2013 State-specific Virginia
Infant & Toddler Connection of Virginia Referral Guide (Infant & Toddler Connection of Virginia) This guide contains information for physicians related to referrals for infants and toddlers with developmental disabilities. The guide includes information on eligibility, what prompts a referral, how referrals are made, and where to make referrals. January 2013 State-specific Virginia
Children’s Integrated Services Referral Form (Vermont Department For Children and Families) This is the referral form developed by Vermont DCF for use with the Children’s Integrated Services Program. The form is used to refer to nursing & family support, early intervention, and early childhood and family mental health services. January 2013 State-specific Vermont
Assuring Better Child Health & Development (ABCD) in Minnesota: 2003 – 2012 (Glenace Edwall, October 2012) This is a set of slides that was presented by Glenace Edwall of the Minnesota ABCD team at the 2012 NASHP Annual Conference in Baltimore, Maryland. The presentation details the history of ABCD in Minnesota and includes information about Minnesota’s ABCD II, ABCD Screening Academy, and ABCD III projects. January 2013 State-specific Minnesota
Minnesota Interagency Consent Form (Minnesota Department of Human Services: 2010) This interagency consent form is designed for the use, disclosure and/or release of personal and health information for purposes of developmental and mental health care coordination. The form is HIPAA compliant and includes a detailed consent for disclosure section. January 2013 State-specific Minnesota
Tools for Creating a Communication and Feedback Loop Between EI and Pediatric Clinics (Minnesota Department of Human Services, 2013) This is a flier developed by Minnesota DHS that details key tasks for clinics and Early Intervention providers to create a feedback work flow. The flier also includes a flow chart displaying how the work flow should work. January 2013 State-specific Minnesota
Children’s Integrated Services Program Handout (Vermont Department for Children and Families) This is a handout for families that was developed by Vermont DCF. The handout describes the purpose of the Children’s Integrated Services (CIS) Program as well as the services it provides to families. December 2012 State-specific Vermont
Children’s Integrated Services Program Booklet (Vermont Department for Children and Families) This is a booklet put together by Vermont DCF to describe the services available to families through the Children’s Integrated Services Program (CIS). The CIS program is the name for Vermont’s approach to providing coordinated child development and family support services. December 2012 State-specific Vermont
Child Find Referral Form (Colorado Department of Education) This is a parental release form for children age 3-5 years – who may need special education services. The form contains an area at the bottom for Child Find to provide an update to the provider. November 2012 State-specific Colorado
Early Intervention Colorado Referral and Release Form (Colorado Early Childhood Connections) Parental release form for infants and toddlers – birth through two years of age – who may need early intervention services. This is an updated form from the one originally developed by Colorado in 2007. November 2012 State-specific Colorado
Arkansas Provider Feedback and Consent Form (AR LINKS: 2012) This is a standardized provider feedback and consent form that was developed by the Arkansas team for the ABCD III project. This form, which is both HIPAA and FERPA compliant, allows physicians to refer to and then receive feedback from providers of Early Intervention services with feedback on referrals to Early Intervention. August 2012 State-specific Arkansas
AR Links Community Cafés and Protocol (AR LINKS: 2012) This is a protocol designed by the Arkansas ABCD III team to be used at Community Cafés designed to raise awareness about the project and the state’s ABCD III work. The protocol is designed to ask participants information about child health and development services, and where they receive their information. The protocol also requests information regarding ways participants believe the delivery systems providing services can be improved. August 2012 State-specific Arkansas
Policies for Care Coordination Across Systems: Lessons from ABCD III (Mary Henderson, Neva Kaye, NASHP/CMWF: June 2012) How can states help primary care providers (PCPs) and community service providers coordinate care? In NASHP’s third Assuring Better Child Health and Development learning collaborative (ABCD III), five state teams (AR, IL, OK, OR, and MN) have piloted projects to systematize care coordination between PCPs of young children with potential developmental delay and community providers, particularly early intervention services. Drawing on eleven years of ABCD experience, these state teams offer model policies and protocols to implement cross-system care coordination. June 2012 NASHP – Commonwealth
Quality Improvement Techniques to Improve Care Coordination (NASHP/CMWF: June 2012) State health agencies can catalyze the development of systems to improve care coordination between primary care and community service providers. This archived NASHP webinar, sponsored by The Commonwealth Fund, focused on lessons from ABCD III states as they developed quality improvement (QI) projects in partnership with physicians and community organizations to improve care coordination for children at risk for developmental delay.  Topics included the state’s role in QI partnerships to design and spread improvements and incentives for physician participation, including maintenance of certification credit. June 2012 Archived  NASHP – Commonwealth Webinar
ABCD III: Lessons Learned Through Year 2 Wilder Research (Minnesota ABCD III Team: February 2012) This document, developed by Minnesota’s project evaluator, Wilder Research, details activities through year 2 of Minnesota’s ABCD III project. It describes pilot site activities, sustainability and spread plans, and lists lessons learned. The document also has several appendixes including one that details recent changes to Minnesota’s Early Intervention system, a summary of key reporting measures, data collection tools, and several interview protocols. June 2012 State-specific Minnesota
ABCD III: Lessons Learned Through Year 2 Summary Wilder Research (Minnesota ABCD III Team: February 2012) This document is a summary of the full report listed above and contains a brief overview of lessons and recommendations through the second year of Minnesota’s ABCD III project. June 2012 State-specific Minnesota
Monthly Status Report (Oregon ABCD III Project: 2012) This is a report form that the Oregon Pediatric Improvement Partnership created for completion by health plans  participating in the Medicaid managed care ABCD III performance improvement project (PIP).  The form provides the state Medicaid agency with an update on the progress of each plan’s ABCD III PIP. June 2012 State-specific Oregon
Early Intervention Resources Website for Parents (Oregon Department of Education: 2012) This website contains information for parents of children who may be at risk for developmental delay. The website includes links to brochures (in English and Spanish) about Early Intervention, links to information for referral to Early Intervention, and more. June 2012 State-specific Oregon
Early Intervention/Early Childhood Special Education Central Directory (Oregon Department of Education: 2012) This website provides links to early childhood state and national resources for parents, providers and the general public. These resources include tools for developmental screening, contact information for parents with concerns about a child’s development, links to organizations that can assist parents of children with disabilities, and more. June 2012 State-specific Oregon
Early Childhood CARES Referral Script (Oregon Early Childhood CARES: 2012) This is a script for intake into Early Intervention (EI) developed by Oregon’s Early Childhood CARES program, which is part of the University of Oregon and funded by the Oregon Department of Education. The script includes questions related to the source that referred the parent to the program. June 2012 State-specific Oregon
Baseline Medical Chart Review Specifications (Oregon ABCD III Project: 2012) This is a document developed by Oregon for health plans participating in the Medicaid managed care ABCD III performance improvement project. It details the processes for sampling and auditing charts for information about developmental screening/concerns, referral to Early Intervention (EI), and feedback from EI. June 2012 State-specific Oregon
Baseline Medical Chart Reviews: Overview and Instructions (Oregon ABCD III Project: 2012) This slideshow provides an overview of the process for reviewing medical charts as part of the Medicaid managed care ABCD III performance improvement project in Oregon. The presentation addresses sampling and measures derived from chart reviews. June 2012 State-specific Oregon
Early Intervention Strategic Interview Template (Oregon ABCD III Project: 2012) This is an interview template developed by the Oregon Pediatric Improvement Partnership that was used to gather feedback from Early Intervention staff about care coordination activities. The template includes questions about referral processes, as well as how to improve information sharing and coordination among Early Intervention and primary care offices. June 2012 State-specific Oregon
Developmental Pediatrician Interview Template (Oregon ABCD III Project: 2012) This is an interview template developed by the Oregon Pediatric Improvement Partnership that was used to gather feedback from developmental pediatricians about care coordination activities. Questions focus on screening and referral processes as well as information sharing with primary care providers. June 2012 State-specific Oregon
Community Provider Strategic Interview Template (Oregon ABCD III Project: 2012) This is an interview template developed by the Oregon Pediatric Improvement Partnership that was used to gather feedback from community service providers about care coordination activities to inform the development of a managed care performance improvement project. The questions include topics such as referrals to Early Intervention/Early Childhood Special Education programs and interaction with medical providers, health plans, and other organizations. June 2012 State-specific Oregon
Baseline MCO Interview Template (Oregon ABCD III Project: 2012) This is an interview template developed by the Oregon Pediatric Improvement Partnership that was used to gather baseline feedback from managed care organizations about care coordination activities to inform the development of a managed care performance improvement project. Questions focus on measurement, screening expectations, reimbursement for care coordination, and referral guidelines and resources. June 2012 State-specific Oregon
Primary Care Provider Interview Template (Oregon ABCD III Project: 2012) This is an interview template developed by the Oregon Pediatric Improvement Partnership that was used to gather feedback from primary care providers about care coordination activities to inform the development of a managed care performance improvement project. Questions focus on topics such as screening, referral and follow up processes. June 2012 State-specific Oregon
Oklahoma Developmental Screening Practice Readiness Assessment (Oklahoma ABCD III Project: 2011) The Oklahoma ABCD III team developed this form to assist practices in determining their readiness to implement developmental screening. The form includes information and questions meant to guide practices in developing office workflow modifications to implement screening. Oklahoma adapted this form from North Carolina’s previous ABCD work. May 2012 State-specific Oklahoma
Oklahoma Developmental Screening Implementation Worksheet (Oklahoma ABCD III Project: 2011) The Oklahoma ABCD III team developed this sheet as a means to assist practices in developing implementation plans for conducting developmental screening. The form asks the practices questions related to completing and scoring screening forms, documenting results, and patient discussion and follow up. Oklahoma adapted this form from North Carolina’s previous ABCD work. May 2012 State-specific Oklahoma
Oklahoma Web Portal Consent Form with HIPAA Compliance (Oklahoma ABCD III Team: 2011) Oklahoma designed this form as a means for securing consent to share patient information over the early childhood services module of the Preventive Services Reminder System (web portal) among primary care providers and the four agencies in the state that provide early childhood services and access the web portal. The form was developed specifically to be HIPAA compliant and contains information for the parents about the four agencies. May 2012 State-specific Oklahoma
Oklahoma Practice Feedback Form Oklahoma ABCD III Team (Oklahoma University Health Sciences Center: December 2011) Upon completion, this document provides primary care practices with an update on the requests for early childhood services that have been made via the electronic web portal. It lists the number of pending, processing, responded, and completed requests and offers reminders for practices when using the web portal. May 2012 State-specific Oklahoma
Key Connection Sheet for Families – Garfield County (Oklahoma ABCD III Project: 2012) This document provides information to families whose children are referred for early childhood services via the electronic web portal. The sheet details the area of expertise and contact information for each of the 4 agencies that provide services and access the web portal. This particular sheet is meant for families in Garfield County, one of the Oklahoma ABCD III pilot counties. May 2012 State-specific Oklahoma
Oklahoma IFSP Summary Form Template (Oklahoma ABCD III Project: 2012) This form was created to serve as a template for practice Individualized Family Service Plan (IFSP) forms. The form identifies fields to be filled out by the early intervention service provider with information specific to the patient. This version of the form is specific to children who are in need of speech therapy. May 2012 State-specific Oklahoma
Identifying and Addressing Barriers to Accessing Early Intervention Services (NASHP/CMWF: May 2012) Early Intervention services can play a valuable role in promoting the healthy development of at-risk infants and young children. All too often, however, families and children who would benefit from Early Intervention services face barriers to accessing them. This Alumni webinar, sponsored by The Commonwealth Fund, focused on a new study that identifies potential barriers to Early Intervention services. Additional speakers discussed strategies to overcome these barriers from both the state Early Intervention perspective and from the state Medicaid and CHIP perspective. May 2012 Archived  NASHP – Commonwealth Webinar
Colorado ABCD Website (Colorado ABCD: 2012) This link directs to the Colorado ABCD project homepage. The site includes information for families, health care providers, and community providers. The website also includes information on screening and referral. April 2012 State-specific Website Colorado
Minnesota ABCD III Project Website (Minnesota Department of Human Services: 2012) This is a website designed by the Minnesota ABCD III Project Team. It includes links to ABCD III tools and resources developed by the project team, ABCD III upcoming events, and tools and resources from other organizations. April 2012 State-specific Website Minnesota
Enhancing Developmentally Oriented Primary Care (Advocate Health Care, Healthy Steps Program; Illinois Chapter, American Academy of Pediatrics) The Enhancing Developmentally Oriented Primary Care Project (EDOPC) is a partnership of Advocate Health Care, Healthy Steps Program and the Illinois Chapter, American Academy of Pediatrics. The project seeks to improve the delivery and financing of preventive health and developmental services for children birth to age three. Much of the EDOPC work is related to, or informs, ICAAP’s ABCD III work. This web site contains up-to-date information on child development and mental health issues, including screening, referral and coding/billing for screenings. April 2012 Website Illinois
Illinois Healthy Beginnings II Webpage Illinois ABCD III Team (Illinois Chapter, American Academy of Pediatrics: 2012) This is the project webpage for the Illinois ABCD III project. The page is administered by the Illinois Chapter, American Academy of Pediatrics, which administers the project in partnership with the Illinois Department of Healthcare and Family Services. The site provides information on project activities, news and reports, and information regarding Maintenance of Certification Part 4. April 2012 State – specific Website Illinois
IHB2 MOC 4 Timeline and Process Sheet for Participants (Illinois ABCD III Team: 2012) This is a sample quarterly reporting tool that the Illinois team developed for practices to collect and report pilot data on developmental screening, referral and feedback as part of participating in Illinois Healthy Beginnings II, the Illinois ABCD III project. This sample tool is for the 18 month developmental screen. The state has also developed similar tools for the 9 and 12 month screens. This tool is meant to assist providers that are seeking to gain MOC part 4 credit and provide data for practice improvement feedback and for the pilot. April 2012 State-specific Illinois
Sample Data Entry and Collection Tool (Illinois ABCD III Team: 2012) This is a sample quarterly reporting tool that the Illinois team developed for practices to collect and report pilot data on developmental screening, referral and feedback as part of participating in Illinois Healthy Beginnings II, the Illinois ABCD III project. This sample tool is for the 18 month developmental screen. The state has also developed similar tools for the 9 and 12 month screens. This tool is meant to assist providers that are seeking to gain MOC part 4 credit and provide data for practice improvement feedback and for the pilot. April 2012 State-specific Illinois
Oklahoma’s Web Portal: Fostering Care Coordination Between Primary Care and Community Service Providers (Larry Hinkle, Carrie Hanlon, NASHP/CMWF: February 2012) This is the second in the series of Assuring Better Child Health and Development (ABCD) III Innovation Briefs. This new brief focuses on the web-based referral and tracking system (“web portal”) that Oklahoma has built into its pre-existing Preventive Services Reminder System. The state designed this web portal to improve care coordination for children with or at risk for developmental delays. Oklahoma is already considering ways to adapt the web portal for other services and populations. February 2012 NASHP – Commonwealth Oklahoma
Oklahoma Care Coordination Web Portal Flow Chart (Oklahoma ABCD III Project: 2012) This slide was developed by the Oklahoma ABCD III team to illustrate the care coordination process and the role of the electronic web portal in facilitating the process. For more information about this process, please see the NASHP/CMWF Issue Brief: Oklahoma’s Web Portal: Fostering Care Coordination Between Primary Care and Community Service Providers (above). February 2012 State-specific Oklahoma
Early Childhood Services Request: ABCD III Oklahoma ABCD III Team (Oklahoma University Health Sciences Center: 2011) This PowerPoint presentation is used by Oklahoma’s practice facilitators to train participating practices on use of the electronic web portal. The presentation includes information on security, how to search and track patients, and referrals. For more information on the web portal please see the NASHP/CMWF Issue Brief: Oklahoma’s Web Portal: Fostering Care Coordination Between Primary Care and Community Service Providers (above). February 2012 State-specific Oklahoma
Building Electronic Information-Sharing Systems to Support Care Coordination in Illinois (Larry Hinkle, Jill Rosenthal, NASHP/CMWF: November 2011) This is the first in a series of Assuring Better Child Health and Development (ABCD) III Innovation Briefs. This brief focuses on electronic information-sharing systems that Illinois is building or adapting to improve care coordination for children with or at risk of developmental delays. Illinois is poised to improve care coordination by implementing an electronic referral initiation and feedback system. These system changes have implications for information sharing to support care coordination statewide and for other populations. November 2011 NASHP – Commonwealth Illinois
Illinois Standardized Early Intervention Referral Form (Illinois ABCD III Project) This form may be used by any service provider to make referrals to early intervention, with releases needed for early intervention to provide information back to both the referring source and the child’s PCP.  The team will continue to make changes to this form in an effort to make it more compatible with state EI reporting systems. October 2011 State-specific Illinois
Illinois Early Intervention Fax Back Form (Illinois ABCD III Project)  This form is used by Early Intervention to report back the status of a referral to the referring source and PCP. Part I is used initially to indicate whether early intervention has been able to reach the family and assign a coordinator. Part II is used later to inform the referring source and PCP about early intervention eligibility and services. The state will continue to make changes to this form in an effort to make it more compatible with state EI reporting systems. October 2011 State-specific Illinois
Improving Care Coordination and Service Linkages to Support Healthy Child Development: Early Lessons and Recommendations from a Five-State Consortium (Carrie Hanlon, Jill Rosenthal, NASHP/CMWF: June 2011) This report summarizes early findings from the current Assuring Better Child Health and Development (ABCD III) learning collaborative of five states. Arkansas, Illinois, Minnesota, Oklahoma, and Oregon are testing models to strengthen linkages and care coordination between pediatric primary care providers and community-based providers of early intervention, mental health, public health, and early care and education services.  The states’ early experiences piloting communication tools, facilitating data sharing, implementing quality improvement processes, and involving families are relevant for efforts to engage multi-sector stakeholders to improve state policy, primary care practice, and population health. June 2011 NASHP – Commonwealth
Tracking Linkages: A Closer Look at Data Tools in Minnesota and Oklahoma
(NASHP/CMWF: June 2011) This is a recording of two state presentations from an ABCD III Evaluation Workgroup Webcast. This recording features presentations from Minnesota on its Access Database and from Oklahoma on its Web Portal. The  speakers described how these data tools 1) track information for the common outcome (and additional measures), 2) fit into clinic or organization office flows, 3) interact with EHRs, 4) change over time, and 5) inform (or might potentially inform) other state projects. June 2011 NASHP – Commonwealth
SoonerStart and Child Guidance Flow Chart (Oklahoma ABCD III Project) This is a flow chart outlining the referral process. It details each activity and responsible parties. January 2011 State-specific Oklahoma
ABCD III Community Site Monthly Report (Oklahoma ABCD III Project) This is the monthly form that Oklahoma’s pilot sites are using to report progress as a part of its ABCD III project. January 2011 State-specific Oklahoma
2011 ABCD III PIP Q & A’s (Oregon ABCD III Project) This is a series of answers to questions that those tasked with implementing the ABCD III Performance Improvement Project may have. Questions deal with topics such as collaboration and External Quality Review Organizations (EQROs). January 2011 State-specific Oregon
Oregon Intergovernmental Agreement (Oregon Department of Human Services) This is an agreement between the Oregon Department of Human Services and the Oregon Health & Science University. It concerns the tasks and scope of work for the ABCD III performance improvement projects conducted by participating managed care organizations. Because of the size of the document it is not currently available on the Resource Center. If you would like a copy please e-mail Larry Hinkle. November 2010 State-specific Oregon
Linking Children to Services: Building on Community Assets to Pilot Test Improvement Strategies (Carrie Hanlon: NASHP) This issue brief describes: 1) how the five ABCD III states are building on existing local partnerships and assets to organize community pilots, and 2) preliminary lessons that have emerged from these states, including new federal opportunities to bolster community partnerships that will improve service linkages for children. December 2010 NASHP – Commonwealth
Improving the Lives of Young Children: Opportunities for Care Coordination and Case Management for Children Receiving Services for Developmental Delay (Carrie Hanlon, NASHP: produced by Urban Institute) This brief examines states’ Medicaid and CHIP policy choices and new opportunities under health reform and other federal legislation to develop a well-coordinated system of care for children receiving Early Intervention and other ongoing services. State examples in the paper draw significantly from ABCD III. December 2010 Peer-reviewed
Improving the Quality of Care and Coordination of Services for Young Children — ABCD, CHIPRA and Beyond! (NASHP) This webinar highlighted how Illinois, Oregon, South Carolina, and Vermont are using ABCD III and/or CHIPRA quality grants to build on and align current efforts, such as medical home initiatives, health information technology or exchange, performance measurement, and health reform, to transform the delivery of care to children covered by Medicaid and CHIP. This event was sponsored by The Commonwealth Fund and built on a session held during the 2010 NASHP Annual Conference. December 2010 NASHP – Commonwealth
United Way of Connecticut 2-1-1 Community Resource Inventory (United Way of CT: 2010) This is the United Way of Connecticut’s 2-1-1 resource inventory. It provides a number of resources broken down by Service Categories October 2010 State-specific Connecticut
United Way of Connecticut 2-1-1 e-Library (United Way of CT: 2010) The e-Library offers substantive information on a number of topics and then links to resources related to those topics. October 2010 State-specific Connecticut
Overcoming Barriers to Referral and Care Coordination for Children Eligible for Early Intervention Services: An ABCD Alumni Webinar
(NASHP: February 2010) This webinar recording contains a presentation done by Scott Allen of the Illinois Chapter of the American Academy of Pediatrics. Mr. Allen discussed lessons learned from a Commonwealth Fund grant to the Illinois Chapter of the American Academy of Pediatrics, overcoming barriers to referral, and care coordination for children eligible for early intervention services. February 2010 NASHP – Commonwealth
Improving Care Coordination, Case Management, and Linkages to Service for Young Children: Opportunities for States (Kay Johnson and Jill Rosenthal: NASHP) States can use primary care practice-based strategies, service provider linkage strategies, and systems change and cross-system strategies to improve linkages to services for young children. This paper uses a framework that illustrates the various roles that states can play to facilitate and support improved linkages: 1) maximizing the use of personnel; 2) undertaking quality improvement initiatives; 3) supporting data, information and technology; and 4) supporting individualized care plans and cross systems planning. April 2009 NASHP – Commonwealth
Enhancing Developmental Outcomes for Children: Help Me Grow Connecticut (Joanna Bogin) PowerPoint presentation describing the structure and development of Connecticut’s Help Me Grow program, a coordinated, statewide referral system that links young children and their families to existing services and support. December 2008 State-specific Connecticut
Developmental services contact information for California counties with 2-1-1- programs (California ABCD Screening Academy Project) Spreadsheet on 2-1-1 service agencies by county, including contact information for the developmental services persons for each county, when available. December 2008 State-specific California
Alaska’s Referral Process for Pilot Sites (Alaska ABCD Project) Flow chart of referral process for pilot sites December 2007 State-specific Alaska
Referral, Evaluation, and Release Form (Colorado Early Childhood Connections) Parental release form for infants and toddlers – birth through two years of age – who may need early intervention services. December 2007 State-specific Colorado
Early Intervention Referral Process for Children Birth to 36 Months (Colorado Early Childhood Connections) Flow chart for Early Intervention Referral Process showing responsibilities of health care provider’s office, Part C Early Childhood Connections, and where responsibilities overlap. December 2007 State-specific Colorado
Colorado Referral Form Colorado Early Childhood Connections (2007) Provider-completed form for recording status and progress of referrals. December 2007 State-specific Colorado
Barriers to the Identification and Management of Psychosocial Issues in Children and Maternal Depression (Sarah McCue Hurwitz, Kelly Kelleher, Ruth Stein, et al. Pediatrics 2007; 119; 208-218) The purpose of this work was to determine whether (1) perceived barriers to care for children’s psychosocial issues and maternal depression aggregate into patient, physician, and organizational domains, (2) barrier domains are distinct for mothers and children, and (3) physician, patient, and practice/organizational characteristics are associated with different barrier domains for children and mothers. (From Introduction) December 2007 Peer-reviewed
Community Resources Inventory (Paula Duncan: Alabama) The purpose of this tool is to structure an approach to identifying community resources that might enhance a practice’s ability to serve their patients. This tool allows practitioners to evaluate which organizations they would like to develop or improve links with. December 2007 State-specific Alabama
Community Resource Data Form (Alabama ABCD Project) The purpose of this tool is to provide a structured approach to collecting information about services in the community that might benefit patients. December 2007 State-specific Alabama
Locating Community-Based Services for Children and Families (Alabama ABCD Project) PowerPoint presentation created to provide stakeholders with information about Alabama’s participation in the ABCD Screening Academy. Presentation provides information on identifying generic and specialized community resources for families and children, birth to five years, and identifying roles for participant involvement in the local ABCD Demonstration Project. September 2007 State-specific Alabama
Agenda for meeting: Locating Community-Based Services to Support Children (Birth to Five) and Families (Alabama ABCD Project) Agenda for meeting held September 26, 2007 to introduce stakeholders to the Alabama ABCD project. September 2007 State-specific Alabama
Linking Children to Developmental Services and Supports: An Overview Amy Fine. (2007). PowerPoint presentation for ABCD Screening Academy Learning Session, July 2007. This presentation focuses on models to improve provider access to follow-up care for families. July 2007 NASHP – Commonwealth
Access to Follow Up Services: Iowa’s Healthy Mental Development Initiative (M. Jane Borst) PowerPoint presentation for ABCD Screening Academy Learning Session, July 2007. This presentation describes Iowa’s model for improving provider access to follow-up care to families: creating designated state-funded staff called EPSDT coordinators. July 2007 NASHP – Commonwealth
Enhancing Developmental Outcomes for Children: Help Me Grow Connecticut Joanna Bogin. (2007). PowerPoint presentation for ABCD Screening Academy Learning Session, July 2007. This presentation describes Connecticut’s model of telephone-based care coordination to improve provider access to follow-up care to families. July 2007 NASHP – Commonwealth
Access to Follow-up Services: Bringing Community and Health Care Providers Together Julie Olson. (2007). PowerPoint presentation for ABCD Screening Academy Learning Session, July 2007. This presentation describes Utah’s model for improving provider access to follow-up care to families: fostering referral pathway development. July 2007 NASHP – Commonwealth
Healthy Babies Kids and Families, Perinatal Communication Tool Vermont ABCD I Project. This form was designed to promote improved care coordination between MCH coordinators, Medicaid providers, and home visiting programs–allowing for a more streamlined approach to improve access to quality services for pregnant women. April 2007 State-specific Vermont
Enhancing Utah’s Capacity to Support Children’s Healthy Mental Development Lori Smith (Salt Lake City, UT: Utah Department of Health, March 2007) This report summarizes findings related to system capacity in Utah. Completed yearly, this assessment consists of a survey tool designed to review and determine the number of professionals qualified to provide services to infants and toddlers from birth to age three. March 2007 State-specific Utah
Beyond Referral: Pediatric Care Linkages to Improve Developmental Health Amy Fine and Rochelle Mayer. (New York, NY: The Commonwealth Fund, December 2006). This report provides a first step in reviewing the current state of pediatric primary care linkage to developmental services, identifying key strategies, developing a linkage typology, and providing recommendations to improve linkage for developmental care. (From web overview) December 2006 NASHP – Commonwealth
How to Develop a Statewide System to Link Families with Community Resources: A Manual Based on Help Me Grow Paul Dworkin, Joanna Bogin, Marijane Carey, et al. (New York, NY: The Connecticut Children’s Trust and the Commonwealth Fund, 2006). The material in this manual is based on Connecticut’s Help Me Grow Initiative, a program of Connecticut’s Children’s Health Fund. This online tool offers guidance for exploring, creating, and/or enhancing a single-point-of-access system to connect children at risk for developmental or behavioral problems with community resources. (From Table of Contents) December 2006 NASHP – Commonwealth
ABCDII Gaps/Barriers to Interventions at the Demonstration Sites Iowa ABCD Project (2006) This resource summarizes results from Iowa’s Care Coordinators survey regarding barriers faced when referring families for services. Particularly, they were asked to document when a needed or recommended service was not available, and why. December 2006 State-specific Iowa
Guiding Principles of Iowa’s System of Developmental Services for Children and their Families Iowa ABCD Project (2006) This resource outlines principles for provider interactions with children, families, and communities developed by the ABCD project and disseminated to providers statewide. December 2006 State-specific Iowa
ABCD II Great Start Minnesota Project Glenace Edwall, Antonia Wilcoxon, Susan Castellano. (Minnesota Department of Human Services, 2006). This presentation provides background information on the Minnesota ABCD II Project. December 2006 State-specific Minnesota
Patient Information and Referral Sheet Minnesota ABCD project. (2006). This document is a standardized patient information and referral sheet used by Minnesota pilot sites and designed to capture referral needs and available services. December 2006 State-specific Minnesota
Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening Council on Children With Disabilities et al. Pediatrics 118 (1): 405. (2006) This statement provides an algorithm as a strategy to support health care professionals in developing a pattern and practice for addressing developmental concerns in children from birth through 3 years of age. The authors recommend that developmental surveillance be incorporated at every well-child preventive care visit. (From Abstract) December 2006 Peer-reviewed
Maternal Depression Resources, Salt Lake County Utah ABCD Project (2006) This resource is a sample matrix of the maternal depression resources available in Salt Lake County during the Maternal Depression Learning Collaborative. December 2006 State-specific Utah
North Carolina Early Childhood Resource List North Carolina ABCD Project. (2006). This document lists current resources relevant to early childhood development service providers and policymakers. December 2006 State-specific North Carolina
Survey of Primary Care Providers: Developmental Screening and Referral for Early Intervention Services North Carolina ABCD Project. (2006). This survey was designed to enable North Carolina staff who were conducting Quality Improvement trainings to gain an understanding of health care providers’ views on, and experience with, developmental screening and referral services. December 2006 State-specific North Carolina
Community Based Resources by County Julie Olson. (UPIQ). A list of community based resources in Utah by county. December 2006 State-specific Utah
Brief Maternal Depression Screening at Well-Child Visits Ardis L. Olson, Allen J. Dietrich, Greg Prazar, et al. Pediatrics Vol. 118 No. 1 July 2006, pp. 207-216. This study examines how routine, brief maternal depression screening conducted during well-child visits was feasible and detects mothers who are willing to discuss depression and stress issues with their pediatrician. (From web overview) July 2006 Peer-reviewed
ABCD Healthy Beginnings Social/Emotional Consultant Consultation Satisfaction Survey Illinois ABCD Healthy Beginnings (2005) This resource is a satisfaction survey given to providers who recently used a Social/Emotional Consultant to access follow-up services for a patient. December 2005 State-specific Illinois
Advanced Training — DC: 0-3R™: Developmentally-
Based Diagnosis of the Mental Health and Developmental Disorders of Infancy and Early Childhood
Zero to Three. (2005). This document outlines training for diagnosing developmentally-based mental health and developmental disorders of infancy and early childhood. This seminar is designed for mental health clinicians who have 1) participated in a full-day Introductory Training on use of DC: 0-3R™, and 2) have been using DC: 0-3R clinically for at least 6 months. December 2005 State-specific Minnesota
What Doctors Should Know About: Early Head Start Utah ABCD Project. (2005) Informational handout summarizing issues related to Early Head Start and suggesting options for advocacy, helping families and further information. December 2005 State-specific Utah
What Doctors Should Know About: Part C Early Intervention Programs Utah ABCD Project. (2005) Informational handout summarizing issues related to Part C Early Intervention Programs and suggesting options for advocacy, helping families and further information. December 2005 State-specific Utah
Developmental Stages of Developmental Screening: Steps to Implementation of a Successful Program Pinto-Martin, Dunkle, Earls, Fliedner, Landes. American Journal of Public Health, 95(November 2005):1928 – 1932. This report explores the challenges of instituting universal developmental screening as part of pediatric care and presents 2 models of existing or planned programs for early screening for autism spectrum disorder and developmental disability (1 in a community-based setting and 1 in a pediatric setting), and discusses the pros and cons of the different strategies. (From Abstract) November 2005 Peer-reviewed
Assuring Better Child Development: Improving Services in Communities Edward Schor. (The Commonwealth Fund, May 20, 2005). A presentation by Edward Schor at the UPIQ Social Emotional Learning Collaborative held in Lehi, Utah, May 20, 2005 that provides information on the consequences of early childhood developmental problems and the value of early intervention. May 2005 State-specific Utah
Introduction to the DC: 0-3™ Diagnosing Mental Health and Developmental Disorders in Very Young Children Molly Romer Witten. (Minnesota ABCD Project, Tuesday, April 26, 2005). This resource is a flyer for an interactive training session that introduces mental health practitioners and other interested professionals to the DC:0-3R, a system for diagnosing the mental health and developmental disorders of very young children. April 2005 State-specific Minnesota
Introduction to the DC: 0-3™ – Diagnosing Mental Health and Developmental Disorders in Very Young Children Minnesota ABCD Project. (April 26, 2005). This interactive workshop introduces mental health practitioners and other interested professionals to a cutting edge system for diagnosing emotional and developmental disorders of very young children. This system, developed by ZERO TO THREE with the help of a diverse task force of infant mental health clinicians and researchers, takes into account the unique sensory, developmental, and relational needs of very young children. April 2005 State-specific Minnesota
Developmental Screening Tools: Web Resources UPIQ. List of web resources: screening tools and related web sites that providers can use to learn more about developmental screening. December 2005 State-specific Utah
Perinatal Depression: Prevalence, Screening, Accuracy, and Screening Outcomes: Summary BN Gaynes et al. AHRQ Evidence Report/Technology Assessment Number 119, February 2005. A systematic review of the evidence on the prevalence and incidence of perinatal depression, the accuracy of screening instruments for perinatal depression, and the effectiveness of interventions for women screened as high risk for developing perinatal depression. (From introduction) December 2005 State-specific Illinois
Addressing Social-Emotional Development and Infant Mental Health in Early Childhood Systems Paula Zeanah, Brian Stafford, Geoffrey Nagle, et al.(Los Angeles, CA: National Center for Infant and Early Childhood Health Policy, January 2005). This report presents an overview of infant mental health (IMH) and the principles that need to be considered when building systems to meet the social and emotional needs of young children. The authors present a number of suggestions about the organization and delivery of IMH services at the state level, as well as some of the problems that are likely to be encountered. (From Introduction) January 2005 Other
California Matrix of Services and Populations California ABCD Project, Screening Matrix (2004) A spreadsheet detailing available Medicaid services and populations receiving services. December 2004 State-specific California
Parents as Primary Partners in Their Child’s Development and School Readiness Kathy Seitzinger Hepburn. (Baltimore, MD: Annie E. Casey Foundation, December 2004). This toolkit has been created for the Annie E. Casey Foundation to help promote early childhood development and school readiness. The purpose of the tool kit is to provide guidance, resource materials, and references that will assist communities in working with families as primary partners in their child’s development and school readiness. (From Introduction) December 2004 Other
Dialing For Help: State Telephone Hotlines as Vital Resources for Parents of Young Children Meg Booth, Treeby Brown, and Malia Richmond-Crumb. (New York, NY: The Commonwealth Fund. November 2004). This brief examines the use of toll-free telephone hotlines by families to obtain advice on their children’s health and well-being. November 2004 NASHP-Commonwealth
Screening Children for Behavioral Developmental Problems NASHP. (Portland, ME: National Academy for State Health Policy, September 2004). News from the Assuring Better Child Health and Development Program: This brief discusses screening, assessment, and developmental surveillance. September 2004 NASHP-Commonwealth
Bright Futures: Guidelines for health supervision of infants, children, and adolescents M Green and J Palfrey (Eds.) (2nd ed.). (Arlington, VA: National Center for Education in Maternal and Child Health, 2nd ed., rev.1994; 2000; 2002). 338 pp., 1 CD-ROM. These Bright Futures guidelines present a detailed framework for health professionals, in partnership with families, to promote the developmental health and well-being of children from birth to young adulthood. (From web overview) December 2002 Peer-reviewed
Early Childhood Assessment Clinic Washington ABCD I Project. (Whatcom County Health Department) This letter was provided to parents whose children had been screened at the Early Childhood Assessment Clinic using the Ages and Stages Questionnaire. It outlines relevant results and referral resource options. August 2002 State-specific Washington
Parents’ Concerns about Their Children’s Development: Prescreening Technique or Screening Test? Glascoe FP, Pediatrics Vol. 99 No. 4 April 1997, pp. 522-528 The purpose of this study was to assess whether parents’ concerns could: (1) serve instead as a screening measure; (2) aid in making focused referral decisions; and (3) help pediatricians target families for developmental promotion and in-office counseling. An additional goal was to determine why most parents’ concerns are accurate although some are not. (From Abstract) April 1997 Peer-reviewed
Improving Care Coordination, Case Management, and Linkages to Service for Young Children: Opportunities for States NASHP-Commonwealth
Improving the Delivery Health Care that Supports Young Children’s Healthy Mental Development: Update on Accomplishments and Lessons from a Five-State Consortium The five states that participated in the second Assuring Better Child Health and Development (ABCD II) Consortium were successful in improving child development services, increasing the rate of identification of children in need of developmental services, and improving the likelihood that those identified with a potential need received appropriate follow-up services. NASHP-Commonwealth

 

 

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