- Time for and confidence in developmental monitoring in primary care practice are still perceived as barriers by providers, despite training that offered specific suggestions for overcoming these barriers.
- Training on the use of the Help Me Grow system significantly addressed provider barriers to referral, specifically concerns about available services and eligibility criteria.
- Tools, or cuing systems, for the simplest and most time efficient monitoring of development and solicitation of parental concerns need to be developed and incorporated into practice with more rigorous effort.
IDENTIFYING BARRIERS TO DEVELOPMENTAL MONITORING
The training program, Strengthening the Developmental Surveillance and Referral Practices of Child Health Providers, supported by The Commonwealth Fund, was designed to address the barriers to providers' early identification and referral of children with, or at risk for, developmental delay. Two data sources provided enumeration of provider-reported barriers and thus set the parameters for design of the intervention program. The first data source included the results of two previous surveys conducted by the American Academy of Pediatrics (AAP) Periodic Survey initiative. The second data source was developed by administering the same two surveys, with minor modifications, to all of the child health providers in the ProHealth (Connecticut) Physicians network. This second survey and data analysis was funded by the American Academy of Pediatrics Research in Pediatric Practice Fund.
Results from AAP Periodic Survey #461 identified the following barriers to providing developmental assessments as part of health supervision: time limitations (cited as important by 80% of respondents), inadequate reimbursement (cited as important by 55% of respondents), lack of non-physician staff to do assessments (cited as important by 51% of respondents), and lack of developmental diagnostic/treatment services (cited as important by 34% of respondents). Despite these barriers, pediatricians overwhelmingly felt that they should address developmental issues (94% of respondents), but those with higher risk patient populations were more likely to cite confidence in their ability to do assessments as a barrier.
AAP Periodic Survey #532 also addressed identification and referral issues in pediatric practice, It was administered two years after the initial study. Similar to the earlier study, time (cited as important by 82% of respondents), lack of office staff to do screening (cited as important by 48% of respondents), and inadequate reimbursement (cited as important by 44% of respondents) were most frequently reported as barriers. Regarding referral to early intervention (EI) services, the most frequently cited barrier was lack of understanding of the EI program's processes and procedures (cited as important by 46% of respondents), followed by lack of information about the EI program and its services (cited as important by 45% of respondents). Other reported barriers included lack of feedback from the EI program about the child's progress/outcomes (cited as important by 36% of respondents), uncertainty about EI eligibility criteria (cited as important by 36% of respondents), lack of time to deal with the EI program (cited as important by <30% of respondents), and failure to incorporate pediatricians' input into EI assessment (cited as important by <30% of respondents).
The Connecticut Center for Primary Care (CCPC), a nonprofit research and education organization dedicated to improving community-based primary care practice in Connecticut and a collaborator on the Commonwealth Fund supported initiative, believed that it was important to explore the extent to which these findings were barriers to identification and referral of children with, or at risk for, developmental delay in Connecticut. We reasoned that using a sample from only one state, with a well established early intervention program (Birth to Three), would limit the variability found in the national study, since all providers would have access to the same set of referral options. In addition, we recognized that family physicians as well as nurse practitioners and physician assistants serve a significant portion of the state's children and should be included in the survey.
The ProHealth Physician network was selected for administration of the national surveys to a Connecticut sample of child health providers. This network was selected for several reasons. It is the largest primary care provider in Connecticut, with sixty family medicine providers and sixty-four pediatric providers, who practice in thirty-two sites throughout central Connecticut. In addition, the ProHealth group is connected in an electronic network that allows for easy distribution of surveys and tabulation of results.
Barriers to screening from the CCPC survey are listed in Table 1. Approximately 80% of all respondents reported time limitations as a significant barrier to screening children younger than thirty-six months, followed by inadequate reimbursement (47%), and lack of office staff to perform screening (38%). Significant differences between the pediatric and family medicine providers were observed for some barriers, but no differences were found between nurse practitioners/physician assistants and physician providers. Family medicine providers were more likely than pediatric providers to feel that lack of knowledge (p < .001), lack of treatment options (p < .002), and lack of confidence in their ability (p < .02) are barriers to screening.
Results of providers' responses to questions about barriers to referral to Birth to Three are presented in Table 2. In general, Connecticut child health providers reported very few barriers to referral, with the majority disagreeing with each stated barrier from the AAP national study. However, family medicine providers consistently reported more barriers, including lack of information about the program, lack of understanding of program processes and procedures, and uncertainty about eligibility requirements (p < .001) They also were more likely to report that there are not services for identified children in their geographic areas (p < .001). This finding was important in designing and implementing an intervention across all community-based sites in Connecticut.
In summary, barriers to early identification of children with, or at risk for, developmental delay that were identified through a combination of national and local provider surveys included time and reimbursement, and, for family practice providers, knowledge about screening techniques and treatment options. Pediatric providers do not report barriers to referral, but family medicine providers need more information about the state's early intervention programs and eligibility criteria. Training was designed to specifically address these issues.
DESIGNING TRAINING TO ADDRESS IDENTIFIED BARRIERS
To address time as a frequently cited barrier to developmental monitoring, the Help Me Grow training message emphasized the time-saving opportunity of using parent-completed questionnaires and soliciting parental concerns about development. The trainer referenced a scenario in which a provider believes a visit to be complete and is on his/her way out the door when the parent says, "Oh, by the way," and proceeds to express serious behavioral concerns. At most training sessions, providers acknowledged familiarity with this all-too-frequent common scenario.
Reimbursement was addressed through the training by emphasizing the time-saving strategies described above and describing coding options for developmental screening.
Knowledge of Practice Options for Developmental Monitoring
Options for integrating developmental monitoring into practice were offered based on research emphasizing the reliability of parental assessments in identifying developmental issues in their children.3 Examples included the use of such parent-completed questionnaires as the PEDS and Ages and Stages, and asking parents the question: "Do you have any concerns about how your child is learning, behaving, or developing?"
Knowledge About Referral Options
Discussion of the Help Me Grow triage system and information on accessible programs and services addressed the lack of knowledge of referral options often cited as a barrier to referral by family physicians.
Knowledge About Eligibility Criteria
The training message emphasized the Help Me Grow goal of enhancing identification and referral of at-risk children not meeting the restrictive eligibility criteria of early intervention programs. Providers were encouraged to not be concerned with eligibility, but to refer all children through age five for whom there are any concerns.
RESULTS OF TRAINING
Following in-office training sessions, providers completed questionnaires asking about the extent to which the training presented them with information that addressed specific barriers to developmental monitoring and referral. Results are presented in Table 3. Overall, providers reported a moderate level of barriers remaining to conducting developmental surveillance (overall barriers rated 3.6 on a 5 point scale, where 5 represented no barriers). The highest rated persistent barrier to developmental surveillance was "lack of time." Multivariate models found that the second highest rated barrier was provider's reported confidence in their own ability to conduct surveillance. These two factors together explained about 30% of the variability in the providers' overall perception of barriers.
Evidence of the extent to which the training addressed identified barriers to referral is presented in Table 4. Overall, providers cited few barriers remaining to their successful referral of children to Help Me Grow.
Analysis of actual referrals made to Help Me Grow after the office training sessions suggests that training addressed barriers related to uncertainty about eligibility criteria. Fourteen percent of calls from trained providers were for children over 3, compared to 6.4% for untrained providers (p < .0001). This suggests that providers understood the intervention message to refer children older than the age limit for Birth to Three. A key aspect of the Help Me Grow program is the linkage to community services that it provides for children with developmental issues who do not qualify for Birth to Three due to age or developmental status. The older age children referred by trained providers is evidence that this message was effectively delivered.
An examination of the calls referring younger children provided further evidence that providers understood this message and that the training addressed barriers related to uncertainty about eligibility criteria. The initial rate of Help Me Grow calls to programs and services other than Birth to Three is 4.4% higher in the trained group than in the non-trained group (Table 5). This suggests that the trained providers are referring more children for concerns that are clearly not eligible for Birth to Three.
In conclusion, the training program was moderately successful in addressing provider barriers to monitoring development. However, it was extremely successful in addressing barriers to referral.
Strengthening the Developmental Surveillance and Referral Practices of Child Health Providers was designed to address, through in office education about developmental monitoring and a statewide information and referral system, the barriers to providers' early identification and referral of children with, or at risk for, developmental delay. Existing barriers were identified from two national surveys and then refined with a survey of community-based providers in Connecticut. Time, reimbursement, knowledge about techniques for developmental monitoring, and knowledge about community resources and eligibility criteria were identified as the key barriers. Success in addressing these barriers was measured with post-education surveys and analysis of referrals made to the state's early intervention services. The educational intervention was moderately successful with regard to barriers to developmental monitoring and highly successful in addressing referral barriers.
Even after training, perceived lack of time remains a formidable barrier to developmental surveillance. Furthermore, child health providers seem reluctant to adopt time-saving tools. They most likely perceive them as more work for staff and themselves. The solicitation of parental concerns, a validated and reliable indicator of developmental delays, may be integrated within the health supervision visit to address time constraints. We recommend exploring strategies to encourage and train providers to adopt this one specific, evidence-based component of developmental monitoring. We also recommend the development and testing of other tools and approaches that do not involve more paperwork, but may be integrated within existing documentation methods.