- Connecticut community-based child health care providers respond positively to on-site training in developmental surveillance and early detection of developmental and behavioral concerns.
- "Academic detailing" can help to ensure that children and families with developmental or behavioral concerns are linked to services through a statewide, coordinated system.
- Health care providers respond to training tailored to individual practice issues with a brief, focused message and useful information.
Child health provider training, supported by the Commonwealth Fund, was developed and implemented in Connecticut to enhance early identification of developmental and behavioral concerns for children from birth to age five. The training also educates providers about how to use the Connecticut Children's Trust Fund's Help Me Grow program for connection to community services and resources. The training was developed and implemented with the belief that the child health provider is uniquely positioned to ensure children's optimal growth and development.1 As noted by Paul Dworkin M.D, "developmental surveillance, with early detection and referral to community resources and services, enhances the role of the health care provider…accomplished by establishing a true medical home that coordinates all services and monitors development in the context of partnering with families to help them raise healthy children." Current research and lessons learned in the Help Me Grow pilot (known as ChildServ), suggested the importance of carefully planning education, training, and follow-up for health care providers. Reaching community-based providers was seen as even more challenging than institutionally-based practices, such as hospital clinics. The latter are more likely to be teaching practices with students and residents, more opportunity to participate in educational sessions, e.g., grand rounds, conferences, and in-service education. Community providers face the challenge of maximizing office visits and charges in order to keep financially solvent, and typically have less time to attend educational sessions.
Research suggests that traditional methods of education (conferences, grand rounds, etc.) have little impact on changing physician behavior. Education alone is not sufficient to motivate changes in practice patterns among providers. The most effective programs are simple, brief, and tailored to the learner. Flexible, on-site programs address individual practice issues more effectively than generalized educational interventions. So-called "academic detailing" incorporates many of the features employed by pharmaceutical representatives during office visits.2
Successful programs are also designed to address specific barriers to change. In a recent national survey, the American Academy of Pediatrics reported that pediatricians overwhelmingly felt that they should address developmental issues, but were not confident in their ability to do so. The specific barriers to performing developmental assessments cited by pediatricians included time constraints, inadequate reimbursement, lack of non-physician support staff, lack of further diagnostic and treatment services, lack of training, and lack of familiarity with assessment tools.3 The Help Me Grow training program was designed to address these barriers.
Patient-mediated programs are seen as reinforcing health provider training. These programs offer tools that encourage parents to discuss their concerns with the health care provider. Help Me Grow uses the Parents' Evaluation of Developmental Status (PEDS) questionnaire, which may be filled out by the parents at the office visit. Information is also given to parents about the Ages and Stages Questionnaires (ASQ), which engages parents in developmental monitoring of their children and is an integral part of Help Me Grow.
Adapting to the Real World-The EPIC Model
Help Me Grow training on developmental surveillance was delivered in collaboration with a newly-developed Connecticut initiative dedicated to providing office-based education and training to child health providers. Educating Providers in their Communities (EPIC) was developed as a program of the Training Resource Academy of the Child Health and Development Institute (CHDI). CHDI, in collaboration with the Connecticut Chapter of the American Academy of Pediatrics, devoted resources to implement the training. It was initiated based on the successful EPIC program developed by the Pennsylvania Chapter of the American Academy of Pediatrics. The goals of EPIC are:
- to advance recent research on health-related issues into clinical practice in the primary care setting;
- to enhance skills of the entire office staff of pediatric and other primary care providers in providing guidance, particularly for at-risk families;
- to identify and disseminate timely, accurate, and evidence-based materials and programs on specified topics for primary care providers;
- to promote the early detection and prevention of childhood developmental and health problems; and
- to promote a system of continuing medical education about children's health that will reach primary health providers in an efficient and cost-effective way.
EPIC provides office-based physician education using trained peer professionals to make onsite presentations to physicians and their staff about specific issues in child health and development. Two components contribute to the uniqueness of this model: a focus on the education of the entire office team, including nurses, physicians, and receptionists by peer professionals; and an emphasis on office-based change using clinical information and practical office tools. The basic EPIC model includes a presentation to the providers and office staff during lunch or at another convenient time. In Connecticut, one or two professionals from the Help Me Grow staff make the presentation. Incentives offered to the practice are CME/CEU credits, lunch, and a free Help Me Grow "Child Development Resource Kit." The training was designed to be brief and flexible. An academic detailing plan was designed and implemented to address the needs of a busy practice, including content, materials, recruitment, enrollment, technical assistance, and follow-up.
Curriculum and Presentation Strategies
The first step in implementing the training program was to develop appealing audiovisual and written materials with key messages to providers about "why you should do this" here. The curriculum components include a summary of developmental surveillance, the uses of the PEDS and the Ages and Stages Questionnaire (ASQ), an overview of the Help Me Grow system, and how to refer for services and resources. The curriculum and training were field tested in five pediatric and family practice sites prior to full implementation. The five sites, selected by Lisa Honigfeld, PhD of the Connecticut Center for Primary Care, reflected a range of practice types and sizes. The pilot sites, two family practices and three pediatric practices, included two solo practices and three group practices of varying size. The five practices were located in different suburban and urban sites and reflected the diversity of providers across Connecticut. Based upon pilot site feedback, as well as informal feedback from Help Me Grow staff and consultants, several changes were made to the curriculum. The presentation was shortened and more focused on what was likely to be most relevant to the practices. For example, information about the program's history and organization was placed at the end of the presentation, if time permitted. The presentation was revised to begin with a description of the system, its benefits to the practice and patients, and how using it will save the provider time. Trainings were enhanced by including pediatricians committed to using developmental surveillance in their practice. Seven "ambassadors," identified as pediatric and family practice "opinion leaders," were identified and oriented to the training curriculum and the Help Me Grow system. Whenever these pediatricians could, they would participate in the training. Although not formally evaluated, the presence of an ambassador seemed to both generate lively discussion and share practical information about surveillance and Help Me Grow.
Training has been provided to more than 150 Connecticut community-based practices over the past year. The training program was designed to: (1) educate and motivate physicians and other child health providers to conduct developmental surveillance of children from birth to age 5; (2) educate and motivate physicians and other child health providers to use the Help Me Grow triage and case management services; and (3) assist providers in systematizing developmental surveillance and the use of Help Me Grow in their practices.
A power point presentation is the central focus of the training. However, we quickly realized that using an LCD and laptop computer is neither efficient nor manageable in many of practices, due to space limitations and staff size. The presentation was therefore modified and placed onto a table-top flipchart. In addition, a three-ring notebook contains color prints of the presentation. The trainers are prepared to use any of the three versions of the presentation for each visit. The presentation includes a total of 21 slides that can be easily delivered in 20 minutes. The key topics are:
- Help Me Grow: a resource that will save you time.
- Developmental surveillance: How it is ongoing, consistent, and valid.
- Parent Questionnaires: Two tools to help identify and address developmental/behavioral concerns.
The presentation includes a diagram of the components of Child Development Infoline and a case scenario to demonstrate how to connect to, utilize, and receive feedback from the system. Use of screening tools, specifically the PEDS and the Ages and Stages Questionnaire (ASQ), is also briefly discussed. Further technical assistance on the use of these tools is also offered.
Two resources are left with the providers to reinforce the information provided in the training. A folder includes a copy of the presentation and samples of Help Me Grow materials ("a prescription pad,"; brochures, the PEDS and Ages and Stages protocols, and articles on developmental surveillance). The "prescription pad" is given by the provider to the parent as a reminder that a referral has been made to Help Me Grow. A Child Development Resource Kit is given to every practice after the presentation. This hanging folder file box has three sections: (1) Help Me Grow materials (brochures, prescription pads, and a laminated "referral guide" to be hung in exam rooms); (2) PEDS protocols and scoring pads with the brief Instruction Guide; and (3) parent handouts on development.
Recruitment and Scheduling
Two strategies were used to enroll providers in the training. An initial mailing was sent to all pediatric and family practices in Connecticut. The letter introduces the Educating Practices in the Community (EPIC) module as a partnership among the Children's Trust Fund, the regional children's hospital (Connecticut Children's Medical Center), and the Connecticut Chapter of the American Academy of Pediatrics and was signed by heads of each organization. An accompanying "Request Form" is to be returned to Help Me Grow by practices interested in participating.
Within six weeks of the initial mailing, approximately 80 providers returned the Request Form asking for a training session to be conducted at their practice. Additional sites also indicated their interest at various professional conferences and at hospital department and committee meetings. Several requests for training were made as a result of providers from other pediatric or family practices that had already been trained. As Request Forms were returned to Help Me Grow, two steps were needed to complete the scheduling process: The designation of a key contract, usually an office manager or nurse manager, who is responsible for making the arrangements, and the identification of the provider "decision-maker" to approve the training. Scheduling was facilitated by a scripted phone call to each office, stating that "Doctor__requested that we schedule this training. With whom shall I speak to make the arrangements?" The script also stated "we are not a pharmaceutical company," as well as referencing the collaborating organization and promising to "discuss resources for the referral of young children with developmental or behavioral concerns."
Practices were more easily scheduled for training if contacted within a day or two of their submitting a request. Because the contact person needed to check the practice schedule and then call back, the process initially took longer than anticipated with some practices not following through. A different strategy was employed as part of a second mailing six months later to streamline the enrollment and scheduling process. A section was added to the Request Form that asked the provider to list possible training dates, eliminating the need for a follow-up call. In addition, when called to schedule the training, each practice was asked if training for any other office sites could also be scheduled.
Feedback and Tracking
Trainers complete an Information Form for each training session and enter the information into a database. Information includes the instructor's name, practice name, location and contact information, training dates, numbers and categories of participants receiving training, continuing medical education requests, and contacts for follow-up and technical assistance. Feedback Forms are distributed to the child health providers and the office staff. A Sign-In Sheet documents participation in each session and indicates requests for Continuing Medical Educational (CME) credits.
Technical Assistance and Follow-Up
Approximately six months after the training session, several follow-up activities were initiated. A letter was sent to the providers thanking them for referring families to Help Me Grow. The mailing included a sign with the message, "Promoting Child Development, We are a Help Me Grow Partner, A Program of the Children's Trust Fund," for display in the waiting room for parents. A Request Form was included offering additional Help Me Grow materials, training, and technical assistance. Unannounced, follow-up visits to practices were well-received and provided an opportunity to leave materials, display the sign, and to maintain the visibility of the program to the providers. Help Me Grow trainers visited previously-trained practices when doing a new training in the same geographic area.
Additional Benefits of Practice Visits
Practice visits offered the opportunity to learn about local issues and specific needs. For example, in the eastern region of Connecticut, three practices reported the need for resources for translating and communicating with patients whose primary language is one of the many Chinese or Indian dialects. Providers reported difficulties in communicating with these parents about basic well-child care and immunizations, and even more difficulties in communicating about the more subtle developmental and behavioral issues. Help Me Grow child development liaisons (CDLs) then contacted local agencies to help identify helpful resources. In several of the practices, pediatricians, nurse practitioners, or physician assistants with skills and training in developmental and behavioral pediatrics were interested in offering developmental assessments to their patients. Several requested technical assistance on incorporating this service into their practice, including information on billing or coding for this type of visit.
Visits are also useful in identifying best practices that support developmental monitoring. For example, one practice employs a developmental pediatrician and a psychologist on a part-time basis to evaluate patients. Another has designed paperless charts with a drop-down list of developmental concerns. One provider serving many poor and high-risk families asks his families to notify him personally when they have connected to a service or resource through the Help Me Grow system.
Trained providers have themselves facilitated the training process. One pediatric provider called after on-site training had been completed to invite Help Me Grow staff to a monthly pediatric community provider meeting at the local hospital. The provider believed that other practices in the community would benefit from knowing about developmental surveillance and the Help Me Grow program. A brief presentation was made and, at the end of the meeting, ten practices requested on-site training. Another pediatrician had been exposed to Help Me Grow during a community-based elective in the Pediatric Residency Program of the University of Connecticut School of Medicine. At her invitation, training was provided in a large practice that she joined following training. Her colleagues now make referrals to Help Me Grow.
CONCLUSIONS AND IMPLICATIONS
Pediatric and family practice providers responded positively to invitations for on-site training on developmental surveillance and the Help Me Grow program. Providers have limited time and require brief, focused information that will be useful to them and their patients. The availability of a system for referring children and families to programs and services is an incentive to talk with the families about their developmental and behavioral concerns, especially for those children who may not be eligible for early intervention and preschool special education services. Training can be adapted for providers in other states informed by the strategies and methods of the Connecticut program.